Palliative symptom management

Data gathering

  • Red flags
  • Others – Shx – family, and support for them, pain, n&v, constipation, PU, breathing, appetite, mood, sleep
  • Examine – depends on symptom

 

Clinical management

  • Investigations
    • AXR, CXR
  • Treatment
    • Pain
      • Paracetamol -> naproxen -> co-codamol -> tramadol -> oramorph/MST
      • Strong opioids – oramorph 5mg 4 hourly  (increase in 50% increments) – if >300mg in 24hr dw palliative care – consider 12 hourly modified release (MST)
        • Oramorph – start at 5mg four hourly for complete pain relief
        • once control achieved, divided 24hour dose by 2 and give MST 12 hourly
        • use 1/6 total daily dose for breakthrough pain
        • as tolerance occurs, add oramorph and divide total dose again once control achieved
        • give laxative, anti emetic
        • patches/injections if unable to swallow
    • Anorexia
      • causes: mood, drugs, sore mouth, obstruction
      • lifestyle: small plates and feeds
      • metoclopramide 10mg TDS, prednisolone 30mg OD
    • Breathlessness
      • causes: pneumonia, effusion, bronchospasm
      • secretions – hyoscine hydrobromide 300mcg TDS
      • bronchospasm – dexamethasone
      • others – o2, nebulised NaCl, bronchodilators, morphine
    • Constipation
      • causes: opioids/dehydration/hypercalcaemia
      • fluids, senna, movicol, glycerol suppository, phosphate  enema
    • Bone pain
      • opiates, NSAIDs, radiotherapy
      • Delirium
      • opioids, drug withdrawal, dehydration, electrolytes.
      • Haloperidol 0.5mg PO or s/c.
      • Nurse in quiet area with minimal noise and good lighting
    • N&V
      • causes: medications, infection, obstruction/constipation, raised calcium, renal failure, raised icp
      • bloods: U+Es, calcium
      • Metoclopramide 10mg TDS
    • Hiccups
      • Metoclopramide, chlorpromazine, gaviscon
    • Anxiety
      • causes
      • Carers, Macmillan nurses
      • SSRI, diazepam 2-5mg TDS, temazepam (insomnia)
    • Haemorrhage
      • sedation, consider emergency referral
    • Hypercalcaemia
      • hydration, bisphosphonates
    • Seizures
      • midazolam/rectal diazepam. consider prophylactic anticonvulsant
    • Spinal cord compression
      • emergency referral
  • Safety net – regular reviews

 

Notes

  • Services available: Community palliative care teams, district nurses, Macmillan nurses, local hospices, social services, benefits
  • With symptoms, always consider the cause
  • Example of syringe driver prescription (for opioid naive patient):
    • Medication (subcutaneous) – dose (in 24hr)
      • Morphine sulphate – 20mg
      • Midazolam – 10mg
      • Haloperidol – 3mg
      • Hyoscine butylbromide – 60mg
        • + PRN for breakthrough – 1/10 to 1/6 of 24 hour dose