General principles palliative care
Palliative care guidelines interactive book
Scottish Palliative Care guidelines
Definitions
Palliative care is defined as the active holistic care of people with advanced, progressive illness.
During the course of the illness, the patient's needs as well as the needs of their family or carers, should be carefully assessed, and consider:
Preferred care setting
Anticipatory prescribing
Physical symptom control: pain, nausea and vomiting, constipation, shortness of breath (dyspnoea), cough, secretions, oral care and anxiety
Psychological needs
Social needs (e.g. help with personal care, housework, and shopping).
The needs of the family and carers
An attempt should be made to estimate the patient's prognosis so that appropriate adjustments can be made to care in the terminal phase.
Eligibility for benefits if diagnosed with a terminal illness
Eligibility: aged 16 to State Pension age, living in UK, life expectancy expected to be 6 months or less
Form DS1500 is completed by a doctor (GP or consultant) and sent to DWP
Entitled to enhanced rate of the daily living component of PIP straight away (fast-tracked application)
Recognising the dying patient
Proactive identification guidance (PIG) (developed by RCGP and National Gold Standards Framework)
Tool identifies patients who may develop palliative needs in the next year to enable forward planning. Three step:
Would the GP be ‘surprised if the patient were to die in the next months, weeks or days’.
Any general signs of decline: declining functional status (which can be measured using the Barthel Index), worsening symptoms and repeated admissions
Any specific signs of decline prognostic to the underlying disease: for example, New York Heart Association stage 3 or 4 in heart failure patients (breathless on minimal exertion).
Patients who are positively identified using PIG should be considered for:
Advance care planning
Physical symptom control
Psychological support
Disease trajectories
Advance care planning
Advanced care planning reduces non-beneficial hospital attendances and facilitates patient choice.
Once completed, an advance care plan can be kept with the patient and carers.
Thinking Ahead pro forma (developed by Gold Standards Framework)
Patients consider what treatment they do and do not want to receive (including resuscitation)
Name a representative in case they are unable to make decisions for themselves in the future.
Terminal phase
Signs suggesting entering terminal phase:
deteriorating day by day
patient expressing a realization that they are dying
reduced cognition, ability to communicate
deterioration in level of consciousness
delirious, confused, agitated
peripherally cyanosed, mottled skin, cold to the touch
altered breathing pattern (Cheyne-Stokes)
The terminal phase may last hours to several days.
Identify symptom needs, spiritual beliefs (such as involving chaplains) and preferred place of death.
Consider subcutaneous syringe drivers
Just in case’ medication
Family members can be taught to administer small oral doses of as-required medication (typically oral morphine) if symptoms are not being adequately controlled.
Such ‘Just in case’ medication needs to be safely stored and have safeguards to prevent misuse.
Specific symptom control
Nausea and vomiting
Metoclopramide or domperidone if gastric stasis or obstruction, as they act as pro-kinetic antiemetics
Haloperidol is used by mouth for most metabolic causes of vomiting (e.g. hypercalcaemia, renal failure)
Cyclizine
Levomepromazine
5HT3-receptor antagonist (e.g. ondansetron) if nausea and vomiting due to cancer chemotherapy
Bowel colic and excessive volume vomiting from bowel obstruction
Hyoscine butylbromide
Hyoscine butylbromide + Octreotide, combination helps reduce the volume of intestinal secretions in vomiting arising from bowel obstruction.
Excessive respiratory secretions
Hyoscine butylbromide or glycopyrronium bromide
Pruritus
Colestyramine
Raised intracranial pressure
Dexamethasone
Cyclizine + Dexamethasone if vomiting due raised intracranial pressure
Restlessness and confusion
Haloperidol
Levomepromazine
Anorexia
Prednisolone
Dexamethasone
Dyspnoea (breathlessness at rest) and intractable cough
Oral morphine reduces the sensation of breathlessness.
Diazepam/Lorazepam + morphine may be helpful for dyspnoea associated with anxiety/distress/panic/agitation
Dexamethasone if there is bronchospasm or partial obstruction.
Pain from bone metastases
Radiotherapy
Bisphosphonates
Radioactive isotopes of strontium chloride (Metastron® available from GE Healthcare)
Neuropathic pain
Tricyclic antidepressant
Antiepileptic
Gabapentin and pregabalin
Pain due to nerve compression may be reduced by a corticosteroid such as dexamethasone
Nerve blocks or regional anaesthesia techniques (including the use of epidural and intrathecal catheters)
Insomnia
Temazepam
Hiccup
Antacid with an antiflatulent
Metoclopramide
Baclofen
Nifedipine
Chlorpromazine hydrochloride
Muscle spasm
Diazepam
Baclofen
Symptoms of hypercalcaemia
Bone pain, thirst, urinary frequency, abdominal pain, vomiting and constipation.
Bisphosphonate (e.g. pamidronate disodium), calcitonin
Symptomatic of dehydration
Consider NG IV SC fluids if there are distressing symptoms of dehydration such as thirst or delirium
Palliative sedation
Palliative sedation is the monitored use of medication to relieve refractory symptoms by inducing various degrees of unconsciousness in patients expected to die within hours or days.
The aim is to achieve a state of ‘conscious sedation’ (the patient wakes sufficiently to respond to verbal stimuli).
The induction of ‘unconscious sedation’ should be considered a measure of last resort.
Palliative sedation remains distinct from euthanasia by application of the following principles:
The intent is to relieve suffering and not hasten death.
The intervention is proportionate to the prevailing symptom.
The outcome is measured by the relief of suffering and not by the death of the patient.
Artificial nutrition and hydration do not necessarily need to be withdrawn during the process of palliative sedation.