P ALLIATIVE C ARE By Hannah Wright GPST1 Teaching 17 th April 2013

General overview of end of life care Cases around prescribing at end of life (and some for symptom control out of interest) Handouts on dosing opioid drugs and antiemetics O VERVIEW

Need to take a good history and examination Importance of continual reassessment Take into account other features (not just physical) as can affect symptoms and response to treatment: Spiritual Emotional Psychological Social Make sure side effects are not worse than the symptoms themselves Ensure good communication with patients and their relatives. G ENERAL P RINCIPLES

Important to recognise Main symptoms noted at end of life: Pain Agitation/terminal restlessness Nausea/vomiting Respiratory secretions (“death rattle”) Dont forget: Stop all unneccessary meds DNACPR and have that discussion with relatives Spiritual needs for patients or relatives Warn families if will need referral to coroner E ND OF L IFE

DrugSymptomRouteDoseFrequencySignature Morphine sulphate Pains/c2.5-5mgprn H.Wright P RESCRIBING AT EOL PRN prescriptions Syringe driver prescriptions Dr H.Wright has prescribed a syringe driver containing the following medications: 1)Diamorphine 10mg 2)Midazolam 10mg

79 year old man with metastatic prostate cancer (bony mets). Admitted for terminal care. Unable to swallow medications. Relevant DH: Zomorph 90mg bd Not needing oramorph as pain well controlled You decide to set up a syringe driver containing morphine. What dose do you prescribe? What PRN dose would you give? In the community, diamorphine is used. What dose would you put in the driver? What PRN dose? C ASE 1

Causes Physical: Nociceptive Neuropathic Non-physical P AIN Assessment History Examination What is causing the pain? Contributing factors Management Medications in use and/or tried before WHO analgesic ladder Neuropathic agents

Doses Start with IR then switch to MR depending on requirements PRN dose is 1/6 total daily dose PRN oral doses take around 30 mins to have an effect O PIOIDS Side effects Constipation Nausea Drowsiness Hallucinations Respiratory depression Toxicity Preparations IR tablets/liquids MR preparations Injectable Patches (Butrans)

Diamorphine Used in the community 3 times more potent than morphine More soluble than morphine O THER O PIOIDS Oxycodone Different side effect profile Better in renal impairment Twice as potent as morphine Hydromorphone May be safer in renal impairment 15x more potent than oramorph Fentanyl Many preparations – buccal, s/l, s/c, patch Used in severe renal failure Alfentanil Better than high dose fentanyl due to volume 30x more potent than oramorph, 10x diamorphine

88 year old lady with end-stage COPD and osteoarthritis admitted for terminal care. Semi-conscious, taking sips of fluid only. Relevant DH: Butrans 20microgram patch weekly Oramorph 5mg prn (uses it very infrequently) On examination, appears comfortable and not in pain. What would you do? What would you prescribe? ****LEAVE THE PATCH ON**** C ASE 2

35 year old lady with metastatic breast cancer, including brain mets. Approaching end of life and seems agitated at times, particularly on movement. What would you consider using to manage her agitation/restlessness? She had previously mentioned that she wants to be more sleepy at the end of life. Would any agent in particular stand out? C ASE 3

Causes Physical discomfort Drugs Infection Brain involvement Biochemical abnormalities Psychological distress R ESTLESSNESS General management Discuss with patient and discuss any psychological distress Involve and support family Relieve physical discomfort Drugs Medications Diazepam Haloperidol Midazolam Levomepromazine Clonazepam Phenobarbital

81 year old lady with very locally advanced gastric carcinoma and constant nausea and vomiting. Relevant DH: Allergic to cyclizine Tried ondansetron and did not like it What would you try next and via what route? What would be important to know about this lady? She is unable to keep any oral medications down. What would you suggest now? C ASE 4

44 year old lady with metastatic breast cancer. In hospice for symptom control and rehab. Having active chemotherapy and finding vomiting very debilitating. However, wants minimal tablet burden. Relevant DH: On 150mg tds cyclizine but still vomiting What could you suggest? Her vomiting is controlled by levomepromazine 6.25mg ON. C ASE 5

Causes Mechanical (e.g. obstruction) Irritants (e.g. Chemo) Metabolic (inc drugs) Raised ICP Anxiety Vestibular disorders N AUSEA AND V OMITING General management Treat cause Non-pharmacological methods – ginger, acupuncture Medications Cyclizine Metoclopramide Domperidone Dexamethasone Ondansetron Hyoscine hydrobromide Prochlorperazine Haloperidol Levomepromazine

S ECRETIONS The “death rattle” Usual drugs: Hyoscine hydrobromide (also useful in colic and bowel obstruction) Glycopyrronium Generally more distressing for relatives than for the patient.

66 year old man with locally invasive rectal carcinoma – eroding buttock. Recognised as being end of life. Agitated, starting to struggle with oral medications. Current medication: Oxycodone MR 120mg bd Midazolam sublingual PRN 2.5mg (using around 3 doses/day) What would you do? C ASE 6

Say he had a CSCI containing oxycodone and midazolam 10mg but still needed multiple breakthrough doses of midazolam, what would you consider doing? The next day you review him. He has required 12.5mg levomepromazine on top of that in the syringe driver and 2 breakthrough doses of 25mg oxycodone s/c. What, if anything, would you do next? C ASE 6 CONTINUED

But don’t worry... As GPST3s we will all get a week at the hospice. And if you work in Swindon, the team are more than happy to offer advice over the phone. There is a Consultant on call 24/7 and they are great resources.

27 year old lady with metastatic cervical cancer – widespread bony metastases and severe pain as a consequence Increasing doses of fentanyl and oramorph breakthrough – at its peak she had 200mcg patches and 120mg oramorph breakthrough, using around 10/day. WHAT NEXT?? C ASE F OR I NTEREST

For severe pain poorly responsive to opioids (but not licensed) Should only be used by specialists and ideally need hospice admission to establish regular dose. Can restore opioid sensitivity so need to be careful they don’t become toxic from other opioids they are taking. Can cause a dysphoria. She was discharged home still with 200mcg fentanyl patches and 20mg QDS ketamine. For the first time in months, she was relatively pain free. K ETAMINE

U SEFUL W EBSITES