Palliative care emergencies are not common but can often be an anticipated event. They will usually be very distressing and therefore need to be managed well. The following guide describes how to minimise patient and family distress.
1. Anticipate the event, ie. identify patients at risk.
2. Draw up an agreed management plan with the patient, family and health care team if possible, eg. whether the patient is to be admitted to hospital or stay at home, what sort of life prolonging measures would be appropriate, who needs to be contacted, etc.
3. Make sure emergency drugs are available in the home: eg. Midazolam 5 10mg s/c (good amnesiac but very short acting and needs to repeated at 15 minute intervals if patient not settling) or Clonazepam drops 0.5-1mg prn s/l (longer acting).
4. Make sure written orders are in the home for the community nurses to be able to give medications, eg. morphine s/c, Midazolam s/c etc.
5. Someone should always remain with the patient - they will be frightened.
6. Always arrange follow up for the family. If poorly managed, palliative care emergencies can cause distress, panic and guilt, especially for carers.
7. Remember morphine is very effective for pain and dyspnoea but is a very poor sedative.
Sudden haemorrhage
Likely to be a terminal event.
Dark green towels should always be near the patient. They will disguise any blood loss (think of theatre gowns).
Erosion of an artery by a malignant ulcer is rare but often catastrophic.
Acute haematesis, fresh melaena, or vaginal bleeding is more common. Think of patients at risk and anticipate.
Acute airways obstruction
Tumours of head and neck, trachea and large bronchi.
Stridor and increasing dyspnoea are preceding symptoms.
If reversible:
Dexamethasone 16mg SC/IV/oral stat then daily
Morphine 5-10mg s/c 4hrly (for dyspnoea).
Consider urgent radiotherapy/stenting.
If not reversible or terminal event:
Midazolam 5-10mg s/c repeated every 15 mins until patient settled (for sedation).
Morphine 5-10mg s/c q4hrs (for dyspnoea).
Hyosine 400mcg s/c q4hrs (for rattly breathing).
Spinal cord compression
Need high index of suspicion
3% of patients with advanced cancer.
Cancer of breast, bronchus and prostate account for 40% of cases.
Thoracic spine most common level of compression (70%).
Presentation
Pain (it starts in my back and comes round the side, its worse when I lie down or cough),
Weakness (my legs wont carry me up the stairs, I find it difficult to stand up),
Sensory level (my legs feel funny),
Sphincter dysfunction
Signs -
Look for upgoing plantars and a sensory level (nipple T4, Umbilicus T10).
Cauda equina: flaccid weakness, sciatica pain both legs, urinary hesitancy/retention.
REQUIRES URGENT ADMISSION
Dexamethasone 16 mg oral/IV/SC stat then daily.
Urgent radiotherapy if appropriate.
The earlier the treatment the more likely the recovery of function.
Panic attacks
Very common
Needs longer term support care and management strategies.
Acute treatment Diazepam 2-5mg tds or Alprazolam 0.25-5mg tds.
Consider antidepressants.
Agitated delirium
Very distressing for patients and family and therefore difficult to manage well at home.
Consider reversible causes (eg. drug/alcohol withdrawal, infection, increased calcium, opioid toxicity, fear, pain, full bladder/rectum, hypoxia).
Haloperidol 5mg O/SC stat.
Repeat every 30 mins until patients settled.
Support and reassurance for family.
Agitated delirium may be part of a terminal event.
SVC obstruction
Think bronchial primary and mediastinal lymphomas.
Usually slow onset (days/ weeks) but can be abrupt.
Symptoms are of venous hypertension: dyspnoea, headaches, swelling of face, neck and arms (tight rings), pink eyes, periorbitol oedema, non pulsatile dilated neck veins, cyanosis.
Give: morphine 5-10mg
SC/oral for dyspnoea
Dexamethasone 16mg
SC/O/IV stat and daily
Oxygen
Alprazolam 0.25-5mg
tds for dyspnoea and anxiety
Consider urgent radiotherapy if appropriate.
Persistant requests for euthanasia
This indicates a palliative care patient (and probably family) in severe distress. Always requires a referral to the palliative care team to support existing carers.
Any comments or queries to jdoran@svh.org.au
Joanne Doran is the area medical director of palliative care.Dr Joanne Doran
jdoran@nor.com.au
Joanne Doran is the area medical director of palliative care for the Northern Rivers Area Health Service based at St Vincents Hospital, Lismore, NSW.
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