1. “Palliative Care” Dr David Plume MBBS DRCOG MRCGP
Macmillan GPF, GP Advisor and Primary Care Network Lead.

2. “Palliative Care” “talk about medicine” or “talk about air”
Enormous subject!
Feedback regarding questionnaires and PPoC
Choice of Topic Areas:
Symptom Control inc Breathlessness and Nausea/Vomiting, setting up a syringe driver.
Current initiatives/developments inc improved drug charts for EOL, transferable DNACPR forms, end of treatment letters etc.
Q and A

3. Local Feedback-Questionnaires
In late 2007 and again in late 2008 I sent out questionnaires looking at twenty nine criteria for palliative care provision in 1’ care.
These included;
Nominated lead?
Keeping a list?
Information getting to 1’ care rapidly enough?
Support for patients on the cancer journey
Frequency of palliative care meetings
Who goes?
H/O forms used and updated?
Are you recording PPoC, concerns etc and using LCP?
Do you have educational input from specialist team?

4. Local Feedback-Questionnaires
Regionally there had been significant improvements between 2007 and 2008.
Increased numbers with a nominated lead, cancer dx list, who were getting better info from 2’ care, palliative care list.
Meetings were now monthly for majority with only small minority having < or > frequency
Meetings continued to predominantly be GPs/DNs and SPCN but 17% of surgeries also have SW
Better recording of attendance/use of h/o forms/provision of benefits advice.
Many more surgeries were making sure they were updating the h/o forms and also patients concerns/expectations and needs.
98% of surgeries use the LCP

5. Local Feedback-PPoC Pilot
Many thanks for your involvement.
Regionally 58% wanted to remain at home, 34% wanted a nursing home/care home and the other 8% wanted to go to hospital.
83% of patient initiated on the document died in their PPoC
Usual reason for not achieving this were care/carer issues or unexpected decline.
Very +ve feedback
With PCT, with costings, for regional rollout.

6. Symptom Control Nausea and Vomiting. Breathlessness.
Setting up a syringe driver.

7. Nausea and Vomiting

8. DEFINITIONS
Nausea “an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms”
Retching “rhythmic, laboured, spasmodic movements of the diaphragm and abdominal muscles”
Vomiting “forceful expulsion of gastric contents through the mouth” – complex reflex process
Nausea is worse than vomiting.
Occurs in 60% of people with advanced cancer.

9. ESTABLISHING the probable diagnosis in NAUSEA & VOMITING
History
Is there any relationship with food or pain – peptic ulcer?
Is it projectile or faeculant – high obstruction?
Did it start with certain medication (eg morphine, digoxin, NSAIDS)?
Do certain events or situations trigger it? (eg hospital, anxiety, chemotherapy)
? Large volume vomit – gastric stasis
Distinguish between vomiting/expectoration/regurgitation
Psychological assessment

10. PATTERN
Nausea relieved by vomiting – gastric stasis / bowel obstruction.
Vomiting shortly after eating or drinking, with little nausea – oesophageal / mediastinal disease
Sudden unpredictable vomit, possibly worse on waking – raised intracranial pressure
Persistent nausea with little relief from vomiting – chemical / metabolic cause

11. EXAMINATION Eyes - Possible jaundice - Examine fundi for papilloedema
Abdomen - Masses
- Hepatomegaly
- Distension / ascites
- Presence or absence of bowel sounds
PR - If constipation suspected
Bloods - Renal & Liver function
- Calcium
- Specific drug levels if indicated

12. MANAGEMENT of NAUSEA and VOMITING
Review of drug regime
Cough = Antitussive
Gastritis = Reduction of gastric acid =
? Stop gastric irritant drugs
Constipation = Laxative
Raised intracranial pressure = Corticosteroid
Hypercalcaemia = IV Saline / Bisphophonate (correction is not always appropriate in a dying patient)
Ascites = ?Paracentesis
R. Twycross 1997

13. MANAGING NAUSEA & VOMITING ANTI-EMETICS
Dopamine receptor antagonists D2
Metoclopramide
Haloperidol
Histamine & muscarinic receptor antagonists H1
Cyclizine
Prokinetic
Domperidone (does not cross BBB)
5HT3 antagonists 5HT3
Granisetron
Tropesitron
Ondansetron

14. MANAGING NAUSEA & VOMITING ANTI-EMETICS
Dexamethasone
? Reduces permeability of BBB to emetogenic substances
Benzodiazepines
Amnesic, anxiolytic & sedative
Cannabinoids
AIDS / chemotherapy
Brainstem cannabinoid receptor
Octreotide
Anti-secretory properties

15. DRUG ADMINISTRATION Oral route suitable for mild nausea.
Syringe driver or rectal route for moderate to severe nausea and / or vomiting.
Anti-emetics should be given regularly rather than PRN.
Optimise dose of anti-emetic every 24 hours.

16. Second-line Anti-emetic Stat dose
CAUSE
First-line
Anti-emetic
Stat
Dose
24 Hr Range
Second-line Anti-emetic
Stat dose
Third-line Anti-emetic other treatments
Gastric stasis /Outlet obstruction
Metoclopramide Or Domperidone
10-20mg
po/im/iv
30-60mg
po/sc/iv
Cyclizine (substitute)
50mg
po/sc
150mg
Po/sc
Consider Dexamethasone (2-8mg / 24hr sc/iv/po)
Consider Asilone
(defoaming agent)
Gastric irritation
Lansoprazole Or
Omeprazole
30mg po po
Metoclopramide
10-20mg sc/iv
Sc/iv
Consider
Levomepromazine or
Ondansetron
Bowel obstruction without colic
sc/iv
Cyclizine or (substitute) Haloperiodol
50mg sc
1.5 –
2.5mg sc
150mg sc
5-10mg sc
Consider Buscopan for colic (60-120mg / 24hr sc)
Consider Dexamethasone to reduce GI oedema (8-16mg / 24hr sc/iv)
Consider Levomepromazine as 3rd line antiemetic ( mg/24hr sc)
Consider Octreotide for large volume vomiting ( mcg/24hr)
Bowel obstruction with colic
Cyclizine
Haloperidol sc
5-10mg
Haloperidol or (add) Cyclizine
2.5 sc

17. Second-line Anti-emetic Stat dose
CAUSE
First-line
Anti-emetic
Stat
Dose
24 Hr Range
Second-line Anti-emetic
Stat dose
Third-line Anti-emetic other treatments
Chemical / Metabolic Drugs eg Morphine, Uraemia Hypercal-caemia
Haloperidol mg
sc/po
1.5-10mg
po/sc
Cyclizine (add)
50mg Sc
150mg
Consider Levomepromazine ( mg/24hr sc)
Ondansetron (8-16mg/24hr po/iv/sc) may help sickness due to uraemia
Raised intracranial pressure
Cyclizine
and
Dexamethasone
50mg sc
8-16mg
po/sc/iv
8-16mg po/sc/iv
Consider Levomepromazine ( mg / 24hr sc)
Motion sickness
Consider Prochlorperazine (25mg pr or 3.6mg buccal)
Cause unknown
And / or
50mg po/sc
Po/sc
Po/Sc
Metoclopramide (substitute)
10 – 20mg
Po/im/iv
30-60mg po/sc/iv
Consider Levomepromazine (6.25–25mg / 245hr sc)
Consider Prochlorperazine (25mg pr or 3-6mg buccal)
Consider Dexamethasone 2-8mg/24hrs Consider Benzodiazepine

18. DRUG ADMINISTRATION Summary of Guidelines
After clinical evaluation, document the most likely cause(s).
Monitor the severity of nausea and vomiting.
Treat reversible causes.
Assess psychological aspects, eg anxiety.
Prescribe first-line anti-emetic for most likely cause both regularly and prn.
Optimize does of anti-emetic every 24 hours.
Reassess and change drugs by adding or substituting the second-line anti-emetic.
- If little benefit, reassess the cause and change to appropriate first-line anti-emetic.
- ?converting to oral route after > 3 days.
- Continue indefinitely unless the cause is self-limiting.

19. Breathlessness

20. Dyspnoea Unpleasant awareness of difficulty in breathing
Physiology
Social
Environmental
Psychology
Unpleasant awareness of difficulty in breathing
Pathological when ADLs affected and associated with disabling anxiety
Resulting in : physiological behavioural responses

21. Dyspnoea
Breathlessness experienced by 70% cancer patients in last few weeks of life
Severe breathlessness affects 25% cancer patients in last week of life

22. Causes of breathlessness-Cancer
Pleural effusion
Large airway obstruction
Replacement of lung by cancer
Lymphangitis carcinomatosa
Tumour cell microemboli
Pericardial Effusion
Phrenic nerve palsy
SVC obstruction
Massive ascites
Abdominal distension
Cachexia-anorexia syndrome respiratory muscle weakness.
Chest infection

23. Causes of Breathlessness-Treatment
Pneumonectomy
Radiation induced fibrosis
Chemotherapy induced
Pneumonitis
Fibrositis
Cardiomyopathy
Progestogens
Stimulates ventilation
Increased sensitivity to carbon dioxide.

24. Causes of Breathlessness- Debility
Atelectasis
Anaemia PE
Pneumonia
Empyema
Muscle weakness

25. Causes of Breathlessness-Concurrent
COPD
Asthma HF
Acidosis
Fever
Pneumothorax
Panic disorder, anxiety, depression

26. Reversible causes of breathlessness!
Resp. Infection
COPD/Asthma
Hypoxia
Obstructed Bronchus/SVC
Lymphangitis Carcinomatosa
Pleural Effusion
Ascites
Pericardial Effusion
Anaemia
Cardiac Failure PE

27. Fear of impending death
Breathlessness Cycle
Anxiety
Fear of impending death
Amplified Panic
Breathlessness
Lack of understanding
Fear of Dying
PANIC

28. Independent predictor of survival
weeks
days
months
Symptomatic drug treatment
Non-drug treatment
Correct the correctable
Breathless on exertion
Breathless at rest
Terminal breathlessness

30. Non-Drug Therapies Explore perception of patient and carers
Maximise the feeling of control over the breathing
Maximise functional ability
Reduce feelings of personal and social isolation.

31. Patient and Carer Perception
Meaning to patient and carer
Explore anxiety esp. fear of sudden death
Inform that not life threatening
State what is likely to/not to happen
Realistic goal setting
Help patient and carer adjust to loss of roles/abilities.

32. Maximize control Breathing control advice Relaxation techniques
Diaphragmatic breathing
Pursed lips breathing
Relaxation techniques
Plan of action for acute episodes
Written instructions step by step
Increased confidence coping
Electric fan
Complementary therapies

33. Maximize function
Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness
Evaluation by physios/OT’s/SW to target support to need.

34. Reduce feelings of isolation
Meet others in similar situation
Day centre
Respite admissions

35. Breathlessness Clinic
Nurse lead
NNUH-Monday Afternoon
Lung cancer and Mesothelioma
Referral by GP/SPCN/Palliative Medicine team/Generalist Consultants
PBL Day Unit-Wednesday, link with NNUH.

36. Drug Treatment
Dyspnoea
Salbutamol
Oxygen
Benzodiazepines
Morphine

37. What do I give?
Bronchodilators work well in COPD and Asthma even if nil known sensitivity.
O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension.
Usual rules regarding COPD/Hypercapnic Resp. failure apply.
Opioids reduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness.
If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed.
If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given
Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2-5mg or Midazolam 2.5-5mg sc
Repeated 4hrly as needed

38. Ongoing treatment
A syringe driver should be commenced if a 2nd stat dose is needed within 24hrs
Diamorphine 10-20mg CSCI / 24hrs
Midazolam 5-20mg CSCI / 24hrs
Remember to prescribe stats
Review & adjust dose daily if needed

39. Terminal Breathlessness
Great fear of patients and relatives
Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI
If agitation or confusion -haloperidol or Nozinan
Some patients may brighten.
Sedation not the aim but likely due to drugs and disease.

40. Respiratory Secretions (death rattle)
Rattling noise due to secretions in hypopharynx moving with breathing
Usually occurs within days-hours of death
Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases)
Patient rarely distressed
Family commonly are distressed
Treat early
Position patient semi-prone
Suction rarely helpful

41. Respiratory Secretions
If secretions are present, two options.
A) Hyoscine Butylbromide (Buscopan)
Stat-20mg 1hrly
CSCI mg/24 hrs
B) Glycopyrronium
Stat-0.4mg 4hrly
CSCI mg /24 hrs
Remember Stats at appropriate doses
Review & adjust dose daily

42. Setting up a syringe driver
YouTube

43. Current Initiatives EOL Drug Charts DNACPR EOT Letters
At piloting stage
Aim to clarify and simplify prescribing at the EOL
DNACPR
“Allow a natural and dignified death”
Development of transferable DNACPR form from 1’2’3’ and visa versa
Piloting later in year
EOT Letters
Much more info, especially on late effects, anticipated problems, points of re-referral etc.
Meet next week with Tom Roques
Integrate with electronic records

44. Q and A
I am not a palliative care physician and you have an excellent resource in Gail!
Happy to answer questions.