- Email: [email protected]
Palliative medicine: medical and psychological aspects
CANCER TREATMENT
Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated. Will enhance quality of life, and may also positively influence the course of illness. Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.1
Palliative medicine: medical and psychological aspects Gwenllian Davies Simon Noble
Abstract Palliative medicine/palliative care is a speciality aimed at symptom control in patients with life-limiting illnesses. Palliative medicine no longer focuses on care of the dying only but is an integral part of the management of patients with a life-limiting illness. It approaches symptom control in a holistic manner addressing a patient’s physical, psychological, social and spiritual needs. This article aims to give an overview of the principles of palliative medicine and guidance on management of particular, frequently seen symptoms, emergencies and end of life care.
Approach to management: Spiritual
Psychological
Social
Every patient and each of their symptoms should be approached with the above structure in mind, taking into account the four different causes/contributory factors to the symptom. For example with pain: physical e pain caused by tumour compression of a nerve psychological e fears about the pain escalating spiritual e why has this happened to me? social e pain affecting function and therefore loss of role in work/family. In order to manage different symptoms a multidisciplinary team (MDT) approach must be taken which includes: doctors i.e. (particularly in cancer management): surgeons oncologists palliative medicine physicians GPs specialist nurses in the above and district nurses physiotherapists occupational therapists social workers councillors (for patients and families). Palliative medicine is no longer confined to a hospice setting and as the members of the MDT shows it is now an integral part of all medical care. Palliative care can and is delivered in a hospital and community setting. Within the community it can be delivered in a patient’s home as well as in nursing homes.
Keywords End of life care; palliative medicine; symptom control
Introduction Palliative medicine as a speciality was first recognized by the Royal College of Physicians in 1987. It has evolved from the hospice movement and a desire to improve symptom control for patients with cancer, but has since developed to encompass other life-limiting illnesses. All aspects of this article are further discussed in the palliative medicine edition of our sister journal ‘Medicine’.
WHO definition of palliative care Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care: Provides relief from pain and other distressing symptoms. Affirms life and regards dying as a normal process. Intends neither to hasten or postpone death. Integrates the psychological and spiritual aspects of patient care. Offers a support system to help patients live as actively as possible until death. Offers a support system to help the family cope during the patient’s illness and in their own bereavement.
Physical symptoms Pain This is a relatively common symptom but is not experienced by every patient.2 As discussed above it should be managed considering the four different categories of contributory/causative factors. We can then break down the management into pharmacological and non-pharmacological. Pharmacological management should be carried out based on the WHO pain ladder3 (Figure 1). In choosing drugs to manage pain it is important to consider the physical cause of the pain. For nociceptive or ‘normal’ pain (caused by tissue injury), the ladder can be followed step by step relying mostly on the non-opioid and opioid analgesics. Non-opioid analgesics include paracetamol, NSAIDs and entenox. However, for neuropathic pain (pain caused
Gwenllian Davies MBChB (Hons) MRCP is a Registrar in Palliative Medicine at Velindre Cancer Centre, Cardiff, UK. Conflicts of interest: none declared. Simon Noble MBBS FRCP PGCE DipPalMed is a Clinical Senior Lecturer and Honorary Consultant in Palliative Medicine, the Department of Palliative Medicine, Royal Gwent Hospital, Newport, Wales, UK. Conflicts of interest: none declared.
SURGERY 33:3
Physical
136
Ó 2015 Elsevier Ltd. All rights reserved.
CANCER TREATMENT
TENS machines (transcutaneous electrical nerve stimulation) complementary therapy (i.e. acupuncture) radiotherapy aids (equipment to aid mobility and activities of daily living) psychological support including counselling(it is important not to overlook this, because if psychological contributions to pain are not addressed then it can become impossible to control pain). Nausea and vomiting As with pain it is important to consider the cause of the nausea and vomiting because different causes will infer different management. For partial obstructive symptoms (e.g. hepatomegaly causing pressure on the stomach) a prokinetic such as metoclopramide should be considered and can be given orally or subcutaneously. Other causes to consider would be electrolyte abnormalities such as hypercalcaemia and uraemia. It would be reasonable to try and correct these while treating the underlying symptoms with an anti-emetic such as haloperidol. Intracranial metastasis may cause nausea and vomiting through raised intracranial pressure and as above treatment of the raised intracranial pressure should be started alongside that for nausea and vomiting. For nausea and vomiting, a change in the route of delivery of medication may need to be considered earlier than for most other symptoms due to malabsorption. In doing this other medications being taken, not only the anti-emetic, should be considered for conversion to the subcutaneous route. It is also of importance to pre-empt these symptoms as they may often be associated with starting opioids or chemotherapy. If the patients are prepared for these symptoms and are co-prescribed an anti-emetic the distress may be reduced (Table 2).
Figure 1
by damage to nerves by compression or injury) adjuvant analgesics such as tricyclic antidepressants or anti-epileptics should be considered earlier. For pain caused by bony metastasis a bisphosphonate should be considered as an adjuvant. It is important to appreciate the equivalent strengths of opioids when prescribing. The potency of commonly prescribed ‘weak’ opioids may have their strength underestimated, leading to untoward side effects in opioid naı¨ve patients. Relative potencies of some common analgesics are given in Table 1. As well as choosing the type of analgesia to be used, the duration of action of analgesia required should be considered. For titration and incident/breakthrough pain a short-acting analgesic is ideal. Breakthrough pain is defined as ‘a transitory exacerbation, or flare of moderate to severe pain that occurs on a background of otherwise stable persistent pain in a patient receiving chronic opioid therapy’.4 Incident pain refers to pain brought on by a voluntary or involuntary action such as walking or sneezing. For stable, constant pain a long-acting analgesic would be chosen. Modes of delivery should also be considered; the first choice of route of delivery as with most other specialities of medicine is oral, but if this is not possible then the subcutaneous/topical/buccal/transdermal routes should be considered (each have their own merits). Non-pharmacological management of pain includes use of the full MDT. Treatments to be considered here are: positioning heatpacks
Constipation This is often seen as a consequence of prescribing opioid analgesics and therefore an easy way to try and avoid this is through co-prescribing of a laxative (Table 3). Other contributory causes would be decreased mobility and decreased fluid intake.
Emergencies in palliative medicine Metastatic spinal cord compression Signs and symptoms of this are back pain, leg weakness, and bladder and bowel disturbance. The management of this is outlined by NICE guidelines5 and some of the recommendations are that an MRI of the whole spine should be carried out within 24 hours of suggestive signs and symptoms. Definitive treatment (spinal surgery or radiotherapy) should be started before any neurological deterioration and ideally within 24 hours of
Common analgesics OPIOID
Oral morphine equivalent
Cocodamol 30/500 2 QDS Tramadol 100 mg QDS Oxycodone 15 mg
24 mg 50e80 mg 30 mg
Prescribing for nausea and vomiting
Table 1
SURGERY 33:3
Cause of nausea
Suggested anti-emetic
Gastrostasis Central
Metoclopramide (caution in obstruction) Cyclizine/haloperidol
Table 2
137
Ó 2015 Elsevier Ltd. All rights reserved.
CANCER TREATMENT
important to address as physical symptoms. Addressing these again involves the MDT. Occupational and physiotherapists will assess a patient’s function and environment in order to recommend techniques and equipment to improve social challenges. It is also important to recognize how financial burdens can become heavier during a period of illness. Hospital visits can increase expenditure while there may well be less income into the household as the patient and carers have had to give up work. In these instances financial support is available through disability allowances and through charitable grants if necessary.
Choosing a laxative Mode of action
Laxative
Stimulant Softener Osmotic
Senna docusate Magnesium hydroxide Macrogols
Table 3
confirmed diagnosis. Immediate management includes bed rest, dexamethasone 16 mg per day and analgesia.
Psychological distress Patients and their families will be emotionally distressed on many occasions along their journey. From being given a diagnosis to being told of worsening disease and a poor prognosis they will have received many psychological blows. Good communication skills at these times of news giving can help improve how the patient and their family come to terms with their disease. All members of the MDT who play a role in these occasions must therefore have appropriate training and skills. However, more than this is often needed. Patients may need formal counselling to come to terms with their situation or may need the time and opportunity to discuss and ask questions of the MDT in order to have a greater understanding of the challenges that lie ahead. During these conversations unrealistic worries or fears may be put to rest. As part of palliative care it is important that the whole family is given time and opportunity to discuss their concerns. This may include questions about the disease or what happens after a person’s death. When children are involved the family may wish to have support in discussing with them what lies ahead or if it is a parent that is suffering with a terminal illness they may wish to make preparations for their children’s future without them. This may include making a will and preparing memory boxes for the children to keep after they have passed away.
Superior vena cava obstruction This is caused by compression or invasion of the superior vena cava by tumour at the mediastinal level. Signs and symptoms are facial swelling, venous dilatation of neck, arm and chest veins, dizziness and shortness of breath. Management is with high flow oxygen, 16 mg of dexamethasone and emergency discussion with the oncology team. Hypercalcaemia A corrected calcium level greater than 2.6 mmol/l equates to hypercalcaemia and should be treated if associated with symptoms. These symptoms may include confusion, drowsiness, nausea and vomiting and weakness. Treatment of hypercalcaemia would be with intravenous (IV) fluids and IV bisphosphonates. Opioid toxicity Signs and symptoms of opioid toxicity are drowsiness, hallucinations, nausea and vomiting, myoclonus and respiratory depression. Management depends on the severity of the toxicity. If toxicity is mild (respiratory rate >8, rousable but complaining of hallucinations) monitor the patient and consider reducing the regular opioid dose. If toxicity is more severe (patient not rousable with a respiratory rate <8), give naloxone 20 mcg IV every 2 minutes until the patient’s respiratory status is satisfactory.6 Smaller doses of naloxone are used in palliative patients on long-term opioids in order to maintain pain control while reversing respiratory depression. Often all the above physical symptoms can be anticipated when you have an understanding of the underlying disease. By preparing ahead with the whole multidisciplinary team involved it is possible to lessen the distress of these symptoms for a patient when they occur. If it is predictable that a patient is going to deteriorate and require new medication or a different route for a medication then the medication should be prescribed in advance, particularly to prevent a crisis out of hours. Anticipatory prescribing like this is important in advance of handing the patient over to a new team (from hospital to community) or from in hours team to on call.
Bereavement care Palliative care does not end with the death of the patient but continues after this with bereavement care for the families. It should hopefully be a continuation of the pre-bereavement work mentioned above. Bereavement care can be just a phone call to a series of one-to-one counselling sessions or a bereavement group. Different charities have different sorts of services that may include children’s bereavement groups which can be accessed by parents or sometimes schools. These groups are of great value as statistics show that bereaved children are at increased risk of mental health difficulties, self harm, risky health behaviours and disturbed education.7 Advanced care planning This is a process by which an individual, in this setting, the patient, discusses their future care preferences with their carers. These carers can include their family or healthcare providers. This can be a formal process resulting in an advanced decision to refuse treatment statement (including decisions not to have cardiopulmonary resuscitation) or appointment of a power of attorney. Advanced care planning can also be less formal resulting in documentation of a patient’s statement of wishes.
Non-physical symptoms The impact of cancer and other life-limiting illnesses is not just physical, and as part of the holistic approach of palliative care other aspects need to be addressed. Social/financial Social isolation and a feeling of loss of identity and purpose can occur due to a life-limiting illness. These symptoms are as
SURGERY 33:3
138
Ó 2015 Elsevier Ltd. All rights reserved.
CANCER TREATMENT
appropriately, and that all are in agreement that the patient is still dying and that appropriate treatment is being given. These assessments should include communication with the family/next of kin to ascertain their concerns and to relay the outcome of the assessments.
Advanced care planning should be undertaken where a patient has a life-limiting illness particularly as it can be anticipated that their condition will worsen and it will become more difficult to establish what their wishes are. Topics for discussion would be any treatment that the patient would not wish to have (e.g. intravenous antibiotics or ventilation), preferred place of care and death, and has the patient written a will. Starting this conversation with a patient may seem daunting but done sensitively and at a time where the patient is ready to discuss these matters can result in a fruitful conversation. Resources are available to assist in having and documenting these discussions. These include: local NHS documentation gold standards framework8 NCPC: The mental capacity Act in Practice e Guidelines for end of life care9 Patient Info leaflet. Authors: Age UK.10
Care after death This encompasses undertaking of the last offices, care of the body in accordance with the patient’s faith and explaining to the family what they need to do next (verbal and written communication). Also informing all relevant healthcare professionals (e.g. GPs) of the patient’s death.
Conclusion The palliative care team plays a crucial role in the management of patients undergoing treatment for cancer, especially when metastatic disease has developed and symptom control is crucial for maintaining a reasonable quality of life. They should be involved when decisions are being discussed about what treatments are appropriate, especially if invasive treatments such as surgery are being suggested. A
End-of-life-care A well-recognized role of palliative care is managing the terminal phase of a patient’s life. The Liverpool Care Pathway (LCP) for the dying patient was developed as a tool to support care in the last hours or days of a person’s life. Recently, use of the LCP, particularly in England, has been phased out following a review by Baroness Julia Neuberger.11 Baroness Neuberger’s report supported the principles underpinning the LCP, which should be the key concerns in ensuring a dignified and symptom-free death. Therefore the following framework for a patient’s care should still be followed and documented in whichever way is used in the clinical environment.
REFERENCES 1 National cancer control programmes: policies and managerial guidelines. 2nd edn. 2002. Geneva: World Health Organization, www. who.int/cancer. 2 Introducing palliative care. 4th edn. Robert Twycross, 2003. 3 Gupta N, Patel FD, Kapoor R, Sharma SC. Pain management in cancer. Internet J Pain, Symptom Control Palliat Care 2007; 5. 4 Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain 1990; 41: 273e81. 5 NICE quality standards e QS56 e metastatic spinal cord compression Feb 2014. 6 www.palliativedrugs.com. 7 Childhood bereavement network’s response to Ofsted’s proposal on the comprehensive care assessment. www.ChildhoodBereavement. org.uk/policyPractice_research.htm. 8 http://www.goldstandardsframework.org.uk/library-tools-ampresources. 9 http://www.nhs.uk/Planners/end-of-life-care. 10 http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS22_ Arranging_for_someone_to_make_decisions_about_your_finance_ or_welfare_fcs.pdf. 11 https://www.gov.uk/government/publications/review-of-liverpoolcare-pathway-for-dying-patients.
Initial assessment This involves the MDT reaching an agreement that the patient is dying and in their last days or hours of life and the appropriate communication of this to the family, to the wider team and with the patient where appropriate. Decisions should be made with regards to which treatments are appropriate to continue with regards to burden versus benefit to the patient, including IV antibiotics and parenteral fluids. Appropriate subcutaneous medication should be prescribed to manage symptoms such as pain, agitation, nausea and respiratory secretions. The patient’s preferred place of death and spiritual needs should also be considered. On-going assessment Included in this is repeated assessment by the MDT that the patient is comfortable and symptoms are being addressed
SURGERY 33:3
139
Ó 2015 Elsevier Ltd. All rights reserved.
Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated. Will enhance quality of life, and may also positively influence the course of illness. Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.1
Palliative medicine: medical and psychological aspects Gwenllian Davies Simon Noble
Abstract Palliative medicine/palliative care is a speciality aimed at symptom control in patients with life-limiting illnesses. Palliative medicine no longer focuses on care of the dying only but is an integral part of the management of patients with a life-limiting illness. It approaches symptom control in a holistic manner addressing a patient’s physical, psychological, social and spiritual needs. This article aims to give an overview of the principles of palliative medicine and guidance on management of particular, frequently seen symptoms, emergencies and end of life care.
Approach to management: Spiritual
Psychological
Social
Every patient and each of their symptoms should be approached with the above structure in mind, taking into account the four different causes/contributory factors to the symptom. For example with pain: physical e pain caused by tumour compression of a nerve psychological e fears about the pain escalating spiritual e why has this happened to me? social e pain affecting function and therefore loss of role in work/family. In order to manage different symptoms a multidisciplinary team (MDT) approach must be taken which includes: doctors i.e. (particularly in cancer management): surgeons oncologists palliative medicine physicians GPs specialist nurses in the above and district nurses physiotherapists occupational therapists social workers councillors (for patients and families). Palliative medicine is no longer confined to a hospice setting and as the members of the MDT shows it is now an integral part of all medical care. Palliative care can and is delivered in a hospital and community setting. Within the community it can be delivered in a patient’s home as well as in nursing homes.
Keywords End of life care; palliative medicine; symptom control
Introduction Palliative medicine as a speciality was first recognized by the Royal College of Physicians in 1987. It has evolved from the hospice movement and a desire to improve symptom control for patients with cancer, but has since developed to encompass other life-limiting illnesses. All aspects of this article are further discussed in the palliative medicine edition of our sister journal ‘Medicine’.
WHO definition of palliative care Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care: Provides relief from pain and other distressing symptoms. Affirms life and regards dying as a normal process. Intends neither to hasten or postpone death. Integrates the psychological and spiritual aspects of patient care. Offers a support system to help patients live as actively as possible until death. Offers a support system to help the family cope during the patient’s illness and in their own bereavement.
Physical symptoms Pain This is a relatively common symptom but is not experienced by every patient.2 As discussed above it should be managed considering the four different categories of contributory/causative factors. We can then break down the management into pharmacological and non-pharmacological. Pharmacological management should be carried out based on the WHO pain ladder3 (Figure 1). In choosing drugs to manage pain it is important to consider the physical cause of the pain. For nociceptive or ‘normal’ pain (caused by tissue injury), the ladder can be followed step by step relying mostly on the non-opioid and opioid analgesics. Non-opioid analgesics include paracetamol, NSAIDs and entenox. However, for neuropathic pain (pain caused
Gwenllian Davies MBChB (Hons) MRCP is a Registrar in Palliative Medicine at Velindre Cancer Centre, Cardiff, UK. Conflicts of interest: none declared. Simon Noble MBBS FRCP PGCE DipPalMed is a Clinical Senior Lecturer and Honorary Consultant in Palliative Medicine, the Department of Palliative Medicine, Royal Gwent Hospital, Newport, Wales, UK. Conflicts of interest: none declared.
SURGERY 33:3
Physical
136
Ó 2015 Elsevier Ltd. All rights reserved.
CANCER TREATMENT
TENS machines (transcutaneous electrical nerve stimulation) complementary therapy (i.e. acupuncture) radiotherapy aids (equipment to aid mobility and activities of daily living) psychological support including counselling(it is important not to overlook this, because if psychological contributions to pain are not addressed then it can become impossible to control pain). Nausea and vomiting As with pain it is important to consider the cause of the nausea and vomiting because different causes will infer different management. For partial obstructive symptoms (e.g. hepatomegaly causing pressure on the stomach) a prokinetic such as metoclopramide should be considered and can be given orally or subcutaneously. Other causes to consider would be electrolyte abnormalities such as hypercalcaemia and uraemia. It would be reasonable to try and correct these while treating the underlying symptoms with an anti-emetic such as haloperidol. Intracranial metastasis may cause nausea and vomiting through raised intracranial pressure and as above treatment of the raised intracranial pressure should be started alongside that for nausea and vomiting. For nausea and vomiting, a change in the route of delivery of medication may need to be considered earlier than for most other symptoms due to malabsorption. In doing this other medications being taken, not only the anti-emetic, should be considered for conversion to the subcutaneous route. It is also of importance to pre-empt these symptoms as they may often be associated with starting opioids or chemotherapy. If the patients are prepared for these symptoms and are co-prescribed an anti-emetic the distress may be reduced (Table 2).
Figure 1
by damage to nerves by compression or injury) adjuvant analgesics such as tricyclic antidepressants or anti-epileptics should be considered earlier. For pain caused by bony metastasis a bisphosphonate should be considered as an adjuvant. It is important to appreciate the equivalent strengths of opioids when prescribing. The potency of commonly prescribed ‘weak’ opioids may have their strength underestimated, leading to untoward side effects in opioid naı¨ve patients. Relative potencies of some common analgesics are given in Table 1. As well as choosing the type of analgesia to be used, the duration of action of analgesia required should be considered. For titration and incident/breakthrough pain a short-acting analgesic is ideal. Breakthrough pain is defined as ‘a transitory exacerbation, or flare of moderate to severe pain that occurs on a background of otherwise stable persistent pain in a patient receiving chronic opioid therapy’.4 Incident pain refers to pain brought on by a voluntary or involuntary action such as walking or sneezing. For stable, constant pain a long-acting analgesic would be chosen. Modes of delivery should also be considered; the first choice of route of delivery as with most other specialities of medicine is oral, but if this is not possible then the subcutaneous/topical/buccal/transdermal routes should be considered (each have their own merits). Non-pharmacological management of pain includes use of the full MDT. Treatments to be considered here are: positioning heatpacks
Constipation This is often seen as a consequence of prescribing opioid analgesics and therefore an easy way to try and avoid this is through co-prescribing of a laxative (Table 3). Other contributory causes would be decreased mobility and decreased fluid intake.
Emergencies in palliative medicine Metastatic spinal cord compression Signs and symptoms of this are back pain, leg weakness, and bladder and bowel disturbance. The management of this is outlined by NICE guidelines5 and some of the recommendations are that an MRI of the whole spine should be carried out within 24 hours of suggestive signs and symptoms. Definitive treatment (spinal surgery or radiotherapy) should be started before any neurological deterioration and ideally within 24 hours of
Common analgesics OPIOID
Oral morphine equivalent
Cocodamol 30/500 2 QDS Tramadol 100 mg QDS Oxycodone 15 mg
24 mg 50e80 mg 30 mg
Prescribing for nausea and vomiting
Table 1
SURGERY 33:3
Cause of nausea
Suggested anti-emetic
Gastrostasis Central
Metoclopramide (caution in obstruction) Cyclizine/haloperidol
Table 2
137
Ó 2015 Elsevier Ltd. All rights reserved.
CANCER TREATMENT
important to address as physical symptoms. Addressing these again involves the MDT. Occupational and physiotherapists will assess a patient’s function and environment in order to recommend techniques and equipment to improve social challenges. It is also important to recognize how financial burdens can become heavier during a period of illness. Hospital visits can increase expenditure while there may well be less income into the household as the patient and carers have had to give up work. In these instances financial support is available through disability allowances and through charitable grants if necessary.
Choosing a laxative Mode of action
Laxative
Stimulant Softener Osmotic
Senna docusate Magnesium hydroxide Macrogols
Table 3
confirmed diagnosis. Immediate management includes bed rest, dexamethasone 16 mg per day and analgesia.
Psychological distress Patients and their families will be emotionally distressed on many occasions along their journey. From being given a diagnosis to being told of worsening disease and a poor prognosis they will have received many psychological blows. Good communication skills at these times of news giving can help improve how the patient and their family come to terms with their disease. All members of the MDT who play a role in these occasions must therefore have appropriate training and skills. However, more than this is often needed. Patients may need formal counselling to come to terms with their situation or may need the time and opportunity to discuss and ask questions of the MDT in order to have a greater understanding of the challenges that lie ahead. During these conversations unrealistic worries or fears may be put to rest. As part of palliative care it is important that the whole family is given time and opportunity to discuss their concerns. This may include questions about the disease or what happens after a person’s death. When children are involved the family may wish to have support in discussing with them what lies ahead or if it is a parent that is suffering with a terminal illness they may wish to make preparations for their children’s future without them. This may include making a will and preparing memory boxes for the children to keep after they have passed away.
Superior vena cava obstruction This is caused by compression or invasion of the superior vena cava by tumour at the mediastinal level. Signs and symptoms are facial swelling, venous dilatation of neck, arm and chest veins, dizziness and shortness of breath. Management is with high flow oxygen, 16 mg of dexamethasone and emergency discussion with the oncology team. Hypercalcaemia A corrected calcium level greater than 2.6 mmol/l equates to hypercalcaemia and should be treated if associated with symptoms. These symptoms may include confusion, drowsiness, nausea and vomiting and weakness. Treatment of hypercalcaemia would be with intravenous (IV) fluids and IV bisphosphonates. Opioid toxicity Signs and symptoms of opioid toxicity are drowsiness, hallucinations, nausea and vomiting, myoclonus and respiratory depression. Management depends on the severity of the toxicity. If toxicity is mild (respiratory rate >8, rousable but complaining of hallucinations) monitor the patient and consider reducing the regular opioid dose. If toxicity is more severe (patient not rousable with a respiratory rate <8), give naloxone 20 mcg IV every 2 minutes until the patient’s respiratory status is satisfactory.6 Smaller doses of naloxone are used in palliative patients on long-term opioids in order to maintain pain control while reversing respiratory depression. Often all the above physical symptoms can be anticipated when you have an understanding of the underlying disease. By preparing ahead with the whole multidisciplinary team involved it is possible to lessen the distress of these symptoms for a patient when they occur. If it is predictable that a patient is going to deteriorate and require new medication or a different route for a medication then the medication should be prescribed in advance, particularly to prevent a crisis out of hours. Anticipatory prescribing like this is important in advance of handing the patient over to a new team (from hospital to community) or from in hours team to on call.
Bereavement care Palliative care does not end with the death of the patient but continues after this with bereavement care for the families. It should hopefully be a continuation of the pre-bereavement work mentioned above. Bereavement care can be just a phone call to a series of one-to-one counselling sessions or a bereavement group. Different charities have different sorts of services that may include children’s bereavement groups which can be accessed by parents or sometimes schools. These groups are of great value as statistics show that bereaved children are at increased risk of mental health difficulties, self harm, risky health behaviours and disturbed education.7 Advanced care planning This is a process by which an individual, in this setting, the patient, discusses their future care preferences with their carers. These carers can include their family or healthcare providers. This can be a formal process resulting in an advanced decision to refuse treatment statement (including decisions not to have cardiopulmonary resuscitation) or appointment of a power of attorney. Advanced care planning can also be less formal resulting in documentation of a patient’s statement of wishes.
Non-physical symptoms The impact of cancer and other life-limiting illnesses is not just physical, and as part of the holistic approach of palliative care other aspects need to be addressed. Social/financial Social isolation and a feeling of loss of identity and purpose can occur due to a life-limiting illness. These symptoms are as
SURGERY 33:3
138
Ó 2015 Elsevier Ltd. All rights reserved.
CANCER TREATMENT
appropriately, and that all are in agreement that the patient is still dying and that appropriate treatment is being given. These assessments should include communication with the family/next of kin to ascertain their concerns and to relay the outcome of the assessments.
Advanced care planning should be undertaken where a patient has a life-limiting illness particularly as it can be anticipated that their condition will worsen and it will become more difficult to establish what their wishes are. Topics for discussion would be any treatment that the patient would not wish to have (e.g. intravenous antibiotics or ventilation), preferred place of care and death, and has the patient written a will. Starting this conversation with a patient may seem daunting but done sensitively and at a time where the patient is ready to discuss these matters can result in a fruitful conversation. Resources are available to assist in having and documenting these discussions. These include: local NHS documentation gold standards framework8 NCPC: The mental capacity Act in Practice e Guidelines for end of life care9 Patient Info leaflet. Authors: Age UK.10
Care after death This encompasses undertaking of the last offices, care of the body in accordance with the patient’s faith and explaining to the family what they need to do next (verbal and written communication). Also informing all relevant healthcare professionals (e.g. GPs) of the patient’s death.
Conclusion The palliative care team plays a crucial role in the management of patients undergoing treatment for cancer, especially when metastatic disease has developed and symptom control is crucial for maintaining a reasonable quality of life. They should be involved when decisions are being discussed about what treatments are appropriate, especially if invasive treatments such as surgery are being suggested. A
End-of-life-care A well-recognized role of palliative care is managing the terminal phase of a patient’s life. The Liverpool Care Pathway (LCP) for the dying patient was developed as a tool to support care in the last hours or days of a person’s life. Recently, use of the LCP, particularly in England, has been phased out following a review by Baroness Julia Neuberger.11 Baroness Neuberger’s report supported the principles underpinning the LCP, which should be the key concerns in ensuring a dignified and symptom-free death. Therefore the following framework for a patient’s care should still be followed and documented in whichever way is used in the clinical environment.
REFERENCES 1 National cancer control programmes: policies and managerial guidelines. 2nd edn. 2002. Geneva: World Health Organization, www. who.int/cancer. 2 Introducing palliative care. 4th edn. Robert Twycross, 2003. 3 Gupta N, Patel FD, Kapoor R, Sharma SC. Pain management in cancer. Internet J Pain, Symptom Control Palliat Care 2007; 5. 4 Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain 1990; 41: 273e81. 5 NICE quality standards e QS56 e metastatic spinal cord compression Feb 2014. 6 www.palliativedrugs.com. 7 Childhood bereavement network’s response to Ofsted’s proposal on the comprehensive care assessment. www.ChildhoodBereavement. org.uk/policyPractice_research.htm. 8 http://www.goldstandardsframework.org.uk/library-tools-ampresources. 9 http://www.nhs.uk/Planners/end-of-life-care. 10 http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/FS22_ Arranging_for_someone_to_make_decisions_about_your_finance_ or_welfare_fcs.pdf. 11 https://www.gov.uk/government/publications/review-of-liverpoolcare-pathway-for-dying-patients.
Initial assessment This involves the MDT reaching an agreement that the patient is dying and in their last days or hours of life and the appropriate communication of this to the family, to the wider team and with the patient where appropriate. Decisions should be made with regards to which treatments are appropriate to continue with regards to burden versus benefit to the patient, including IV antibiotics and parenteral fluids. Appropriate subcutaneous medication should be prescribed to manage symptoms such as pain, agitation, nausea and respiratory secretions. The patient’s preferred place of death and spiritual needs should also be considered. On-going assessment Included in this is repeated assessment by the MDT that the patient is comfortable and symptoms are being addressed
SURGERY 33:3
139
Ó 2015 Elsevier Ltd. All rights reserved.