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Emergencies in Palliative Care

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Continue q15 minutes until pain score reduced by 50%, or adverse ... Chemotherapy SCLC, NHL. Radiation - NSCLC. Bed rest with head elevated. Oxygen. Diuretics ... – PowerPoint PPT presentation

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Title: Emergencies in Palliative Care


1
Emergencies in Palliative Care
  • C. Woelk MD, CCFP, FCFP
  • Medical Director of Palliative Care RHA Central
    Manitoba
  • Physician, Community Cancer Program Boundary
    Trails Health Centre
  • Family Physician Winkler, MB

2
Oxymoron
  • Definition
  • Two concepts that do not really go together, but
    are used together
  • A phrase containing two contradictory terms

C. Woelk MD
3
Oxymoron Examples
  • Old news
  • Extensive briefing
  • Random order
  • Free gift
  • Palliative Emergencies

C. Woelk MD
4
Objectives
  • To appreciate the concept of palliative
    emergencies
  • To review a number of the potential emergencies
  • To develop an approach of prevention, and early
    diagnosis and management

C. Woelk MD
5
Mandatory Underlying Premise
Orders
Actions
Palliative Care Do not resuscitate / DNR Allow
Natural Death / AND Advanced Care Plan / ACP 4
Do not intervene Ignore Sedate
?
C. Woelk MD
6
Managing Palliative Emergencies
  • Prevention
  • Anticipating the Potential
  • Early Recognition
  • Appropriate Response
  • Communication

Communication
C. Woelk MD
7
An ounce of prevention is worth a pound of
cureBenjamin Franklin
C. Woelk MD
8
Anticipation
  • Be aware of potential emergencies
  • Be aware of patient wishes in case of emergency
  • Be aware of family member wishes in case of
    emergency

C. Woelk MD
9
Questions to ask Yourself
  • Is this person palliative?
  • Is this an emergency?
  • Is this event reversible or is this a terminal
    event?
  • Is reversing this event reasonable?
  • Emergent syndrome management vs. Emergent symptom
    management

C. Woelk MD
10
Is this person palliative?
Death
Diagnosis
Disease-oriented treatment
Symptom-oriented treatment
Bereavement
Palliative Care
Terminal Care
C. Woelk MD
11
Is this person palliative??? How palliative ??
Increasingly Aggressive Life- Prolonging Measures
Increasing Palliative Care
C. Woelk MD
12
Is this emergency?
  • What is an emergency?
  • Who defines this as an emergency?

C. Woelk MD
13
Is this a reversible event?
Is reversing this event reasonable?
C. Woelk MD
14
Is reversing this event reasonable?
C. Woelk MD
15
Emergent syndrome management?SometimesEmergent
symptom management?Always
C. Woelk MD
16
Potential Goals in Treating Palliative Emergencies
  • Improvement in function
  • Decrease in symptoms
  • Prolongation of life
  • Improved quality of life
  • Less complicated bereavement

C. Woelk MD
17
Working with excess Adrenalin in the room
  • Anxiety
  • Fear
  • Panic
  • Fight

C. Woelk MD
18
Pain Crises
This is as much of a crisis as a code
Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
19
Definition of Pain Crisis
  • An event in which the patient reports severe
    uncontrolled pain that is the patient, family or
    both severe distress.
  • The pain may be acute in onset or have progressed
    gradually to an intolerable threshold (as
    determined by the patient), but requires
    immediate intervention.

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
20
Severe Pain CrisisIncidence
  • No epidemiological data available that describes
    incidence

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
21
Severe Pain CrisisEtiology
  • Most common potential sources
  • Acute fracture
  • Ruptured organ
  • Nerve compression

C. Woelk MD
22
Severe Pain CrisisApproach
  • Rapid thorough clinical assessment
  • Titration of analgesics
  • Direct supervision by individuals or a team
    familiar and comfortable providing this care

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
23
Severe Pain CrisisApproach
  • Rapid thorough clinical assessment
  • The extent of the workup depends on the clinical
    situation
  • i.e. the goals of care, patients wishes, and the
    risk-burden ratios of tests and their
    implications

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
24
Severe Pain CrisisApproach
  • 2. Titration of analgesics
  • Convert oral to IV equivalents
  • Give one breakthrough dose (BTD) repeat in 15
    minutes
  • If pain remains gt 7/10, double the BTD
  • Continue q15 minutes until pain score reduced by
    50, or adverse events occur
  • Calculate new 24 hour, and BTD after pain relief
    obtained.
  • Adjust route of administration

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
25
World Health Organization Pain Ladder
?
Step 3
Opioid for moderate to severe pain /-
Non-opioid /- Adjuvant
Step 2
Opioid for mild to moderate pain /-
Non-opioid /- Adjuvant
Step 1
Non-opioid /- Adjuvant
Increasing Pain
C. Woelk MD
26
Severe Pain CrisisApproach
  • 2. Titration of analgesics
  • Remember the use of adjuvants
  • Remember opioid rotation
  • Expect emotional response from family and other
    caregivers

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
27
Severe Pain Crisis - Approach
  • 3. Direct supervision by individuals or a team
    familiar and comfortable providing this care
  • One of the pearls of wisdom that we talked about
    as a team the next day is that in situations at
    the end of life, its really important to get
    people involved just as if someone was having a
    heart attack. In that case, you would call a
    cardiologist. If someone had a dropped lung, you
    would call a surgeon. In a similar way, you have
    to treat someone who is terminal, meaning death
    being imminent, as almost a code, in the sense
    that you have to get the people involved who can
    best provide care at that point.

Moryl N, Coyle N, Foley K. JAMA
2008299(12)1457-1467.
C. Woelk MD
28
Spinal Cord Compression
  • Compression of the spinal cord somewhere along
    its length by a primary or secondary malignancy

C. Woelk MD
29
Spinal Cord CompressionIncidence
  • 5 of all cancer patients
  • Average age 58
  • Vertebral column is the most common site of
    skeletal metastases
  • Up to 30 of patients with metastatic
    compression will survive more than 1 year after
    first symptoms

C. Woelk MD
30
Spinal Cord CompressionSite of Cancer Origin
  • Lung 16
  • Breast 12
  • Unknown 11
  • Lymphoma 11
  • Myeloma 9
  • Sarcoma 8
  • Prostate 7
  • Kidney 6

C. Woelk MD
31
Spinal Cord CompressionInvestigation
  • Spine x-rays
  • Bone scan
  • MRI test of choice
  • (CT Myelography
  • former test of choice)

C. Woelk MD
32
Spinal Cord CompressionTreatment
  • Rapid diagnosis and therapeutic intervention is
    essential
  • Paraplegia from malignant SCC is always
    irreversible and is no longer an emergency
  • Immediate high dose steroids
  • Dexamethasone 100 mg i.v. then 4 () mg q6h
  • Radiation
  • Surgery
  • Chemotherapy

C. Woelk MD
33
HypercalcemiaIncidence
  • 10 of advanced cancers
  • May be the first presentation of multiple myeloma

C. Woelk MD
34
HypercalcemiaIncidence
  • Breast cancer (gt20)
  • Non-small cell lung cancer (25)
  • Hypernephroma
  • Multiple Myeloma (40-50)
  • Squamous cell cancers of head, neck, esophagus
  • Thyroid cancers
  • Prostate, Small cell lung cancers and colorectal
    cancers have small incidence, despite frequently
    metastasizing to bone

C. Woelk MD
35
HypercalcemiaEtiology
  • Bone metastases / osteoclastic action
  • PTH-like substances
  • Dietary factors are generally not considered
    important in developing hypercalcemia

C. Woelk MD
36
HypercalcemiaPresentation
  • Early symptoms and signs
  • Polyuria, nocturia, polydipsia
  • Dehydration
  • Anorexia
  • Easily fatigued / weakness
  • hyporeflexia

C. Woelk MD
37
HypercalcemiaPresentation
  • Late symptoms and signs
  • Neuropsychological apathy, irritability,
    depression, decreased concentration, coma
  • Profound muscle weakness
  • Gastrointestinal nausea, vomiting, abdominal
    pain, constipation, increased gastric secretions,
    acute pancreatitis
  • Pruritis
  • Visual disturbances
  • Cardiac arrythmias

C. Woelk MD
38
HypercalcemiaInvestigation
  • Serum Calcium
  • Serum Albumin

CaCORR CaMEAS (0.02 x albNORM albMEAS)
C. Woelk MD
39
HypercalcemiaInvestigation Example Calculation
  • Serum Calcium 2.48 mmol/L (N 2.2-2.6)
  • Serum Albumin 17 g/L (N 35-45)

CaCORR CaMEAS 0.02 x (albNORM albMEAS)
2.48 0.02 x (40-17) 2.48
0.46 2.94
C. Woelk MD
40
Hypercalcemia
  • Calcium levels
  • Normal 2.2 2.6
  • Mild 2.7 2.9
  • Moderate 3.0 3.2
  • Severe 3.3 3.7
  • Life-threatening gt 3.7

C. Woelk MD
41
HypercalcemiaEKG findings
  • Shortened QT interval (Ca gt 3.2)
  • Prolonged PR and QRS intervals
  • Increased QRS voltage
  • T-wave flattening and widening
  • Notching of QRS
  • AV block, progressing to complete heart block and
    cardiac arrest (Ca gt 3.7)

C. Woelk MD
42
HypercalcemiaTreatment
  • Consider the goals
  • Hydration and saline diuresis
  • Bisphosphonates
  • Steroids

C. Woelk MD
43
Superior Vena Cava Syndrome
  • The clinical manifestation of superior vena cava
    (SVC) obstruction, with severe reduction in
    venous return from the head, neck and upper
    extremities

C. Woelk MD
44
Superior Vena Cava SyndromeIncidence and Etiology
  • Usually associated with malignancies
  • Often the initial presentation of cancer
  • Bronchogenic carcinoma (80)
  • Lymphoma (15)
  • Metastatic disease (5)

C. Woelk MD
45
Superior Vena Cava SyndromePresentation
  • Symptoms
  • Dyspnea 63
  • Facial and neck swelling 50
  • Fullness in head 50
  • Cough 24
  • Arm swelling 18
  • Chest pain 15
  • Dysphagia 9

C. Woelk MD
46
Superior Vena Cava SyndromePresentation
  • Signs
  • Venous distention of neck 66
  • Venous distention of chest wall 54
  • Facial edema 46
  • Cyanosis 20
  • Edema of the arms 14
  • Plethora of the face 10
  • Vocal cord paralysis 3
  • Horners syndrome 3

C. Woelk MD
47
Superior Vena Cava SyndromeManagement
  • Does not usually imply immediate threat to life,
    except when trachea or pericardium is compromised
  • Important is to establish a diagnosis
  • Emergency treatment indicated if
  • Compromised airway
  • Decreased cardiac output
  • Cerebral dysfunction

C. Woelk MD
48
Superior Vena Cava SyndromeManagement
  • Chemotherapy SCLC, NHL
  • Radiation - NSCLC
  • Bed rest with head elevated
  • Oxygen
  • Diuretics
  • Steroids

C. Woelk MD
49
Severe hemorrhageEtiology
  • Epistaxis
  • GI bleeding
  • Hematemesis,Hematochezia,Melena
  • Hemoptysis
  • Hematuria
  • Internal Bleeding
  • Bleeding from fungating tumours
  • Hemolysis

C. Woelk MD
50
Severe hemorrhageImportant General Questions
  • Is treatment of the underlying condition possible
    in the context of the bleeding?
  • Is it possible to keep up with the loss of blood,
    and for how long?
  • These may need to be addressed early, with the
    patient, family and caregivers.

C. Woelk MD
51
GI BleedingIncidence and Etiology
  • 80 of GI bleeding in cancer patients is from
    benign sources good prognosis
  • Massive hemorrhage is unusual
  • ESOPHAGUS
  • STOMACH
  • SMALL INTESTINE
  • COLORECTUM

C. Woelk MD
52
GI BleedingManagement
  • Consider gastroscopy / colonoscopy / surgery if
    life expectancy reasonable.
  • Avoid surgery if life expectancy lt 2 months
  • Stop potentially offending agents e.g. NSAIDs
  • Consider IV fluids, PPI

C. Woelk MD
53
GI BleedingManagement
  • Massive Bleeding in the Terminal Phase
  • Keep patient warm
  • Consider sedation
  • Green towels

C. Woelk MD
54
HemoptysisIncidence and Etiology
  • Present in 30-50 of primary lung neoplasms at
    the time of presentation
  • 10 of patients admitted to hospice
  • Massive hemoptysis uncommon
  • Pulmonary embolism
  • Bronchial bleeding due to tumour erosion
  • Epistaxis

C. Woelk MD
55
Massive HemoptysisManagement
  • Trendelenburg position
  • Consider sedation
  • Green towels

C. Woelk MD
56
Wound BleedingIncidence and Etiology
  • Bleeding is a common problem with malignant
    wounds
  • May involve oozing from microvascular
    fragmentation to frank bleeding if vessels are
    involved

C. Woelk MD
57
Wound BleedingManagement
  • For patients with malignant wounds, it will not
    be possible to heal the wound, unless one can
    treat the underlying cancer.
  • Avoid adherent dressings.
  • Keep the wound moist.
  • Direct pressure, if actively bleeding
  • Medicated dressing possibilities
  • Topical thromboplastin
  • Topical aminocaproic acid
  • Topical dilute silver nitrate solutions

C. Woelk MD
58
Wound BleedingManagement
  • If bleeding is possible, discuss this with the
    patient and family and staff
  • If bleeding is catastrophic, dark towels may
    reduce anxiety of all involved
  • If the patient is distressed, consider sedation

C. Woelk MD
59
Severe HemorrhageSystemic Interventions
  • D/C antiplatelet and anti-thrombotic agents
  • Vitamin K
  • Transfusion of blood or platelets
  • Antifibrinolytic Medication
  • Tranexamic acid
  • Aminocaproic acid
  • Desmopressin
  • Octreotide (somatostatin analog)

C. Woelk MD
60
Severe Hemorrhage - Management
  • Antifibrinolytic Agents
  • Prevent clot lysis by blocking the binding sites
    of plasmin and its activators
  • Tranexamic Acid (1.5 g, then 1 g tid PO)
  • Aminocaproic Acid (5 g, then 1 g qid PO)
  • May be effective topically
  • Main s/e dose-related nausea, vomiting, diarrhea
  • Avoid in upper urinary tract bleeding
  • May not be helpful in thrombocytopenic bleeding

C. Woelk MD
61
Severe Hemorrhage - Management
  • Desmopressin (DDAVP)
  • An analog of the posterior pituitary hormone
    vasopressin
  • Extensively used in Type 1 von Willebrand Disease
  • 0.3-0.4 mcg/kg IV over 20 minutes OR 150-300 mcg
    nasal inhalation
  • Has been used successfully in acquired defects of
    platelet function e.g. uremia, cirrhosis, ASA
    and in variceal bleeding
  • Avoid excessive fluid administration

C. Woelk MD
62
Severe Hemorrhage - Management
  • Octreotide (Somatostatin analog)
  • 100-600 mcg/day given in 2 or 3 doses
  • Alters the physiological response to bleeding
  • Results in decreased splanchnic bloodflow,
    reduced venous pressures, cytoprotection,
    suppression of gastric acid secretion

C. Woelk MD
63
Severe HemorrhageManagement
  • Remember the goals of care
  • Keep patient, family, staff informed of progress
    and prognosis

C. Woelk MD
64
Respiratory DistressIncidence
  • Prevalence of Dyspnea is variably reported
    (21-79)
  • Assessment of dyspnea has not been consistent
  • Progressive dyspnea is much more common than
    acute onset dyspnea

C. Woelk MD
65
Respiratory DistressEtiology
  • Progressive Hypoxia
  • Progressive Hypercapnia
  • Pneumonia
  • Pulmonary Embolism
  • Obstruction

C. Woelk MD
66
Respiratory DistressManagement
  • General Measures
  • Position of comfort
  • Reassurance / Relaxation techniques
  • Well-ventilated area / open windows/ use fans
  • Medications
  • Opioids PO/SC/IV depending on urgency and
    access
  • Oxygen
  • Salbutamol
  • Benzodiazepines
  • Clorpromazine
  • Steroids

C. Woelk MD
67
Management of Sudden Progressive Respiratory
Distress / Respiratory Panic
  • Someone MUST remain with the patient
  • Aggressive Opioid management, similar to managing
    Pain Crisis
  • Expect RR to decrease and the patient to become
    more comfortable
  • Explanation
  • Consider sedation

C. Woelk MD
68
SeizuresIncidence
  • 1 of patients with advanced cancer
  • Higher incidence in children with underlying
    progressive neurological disorders

C. Woelk MD
69
SeizuresEtiology
  • Most common
  • Primary or metastatic brain tumours
  • CVA / Stroke
  • Pre-existing seizure disorder
  • Less common
  • Hypoxemia
  • Metabolic uremia, hypoglycemia, hyponatremia
  • Sepsis
  • Drug or alcohol withdrawal

C. Woelk MD
70
SeizuresManagement
  • Educate / Seizures are frightening, especially to
    family
  • Concerns
  • Will he swallow his tongue?
  • Will she choke to death during a seizure
  • Will the seizure cause brain damage?
  • Will the seizure cause death?

C. Woelk MD
71
SeizuresEducation
  • What to do if a seizure happens
  • Help avoid harm / trauma
  • Do not restrain
  • Do not attempt to insert anything orally
  • Recovery position after the seizure
  • Expect drowsiness for a while after
  • Call for help if seizure lasts more than 5
    minutes (it will feel like 30)

C. Woelk MD
72
SeizuresManagement
  • Investigate as appropriate, based on patients
    status and course
  • Generally felt unnecessary to give routine
    prophylaxis for seizures
  • Grand Mal Seizures Phenytoin is first drug of
    choice
  • Focal Seizures Carbamazepine is first drug of
    choice
  • Other anticonvulsants may be needed

C. Woelk MD
73
Status epilepticusDefinition
  • Continuous seizure activity for gt 30 minutes
  • Two or more seizures, one after the other,
    without recovery of consciousness in between

C. Woelk MD
74
Status epilepticusManagement
  • Protect airway
  • Administer Oxygen
  • Consider IV

C. Woelk MD
75
Status epilepticusMedications
  • IV available
  • Lorazepam 2-4 mg over 2-4 minutes
  • Phenytoin load 20 mg/kg at 25 mg/min
  • May need to go as high as 30 mg/kg
  • Phenobarb 20 mg/kg at 100 mg/min
  • IV unavailable
  • Diazepam 10 mg solution PR
  • May be repeated q10minutes
  • Midazolam SC infusion 1-3 mg / hour
  • Consider steroids

C. Woelk MD
76
Multifocal Myoclonus
  • Jerking, involuntary movements of arms and legs
  • May start as subtle movements, and then become
    bothersome and disturbing

C. Woelk MD
77
Multifocal MyoclonusIncidence
  • Difficult to determine, especially with various
    etiologies
  • Seems a common problem

C. Woelk MD
78
Multifocal MyoclonusEtiology
  • Very often associated with delirium and related
    to opioid toxicity
  • May be a pre-terminal event
  • Important to consider the differences

C. Woelk MD
79
Opioid Neurotoxicity
  • Cognitive Dysfunction
  • Myoclonus
  • Hyperalgesia
  • Allodynia
  • Perceptual Disturbance
  • Seizures

C. Woelk MD
80
Delirium in advanced cancer
  • Reversible in 40-60 of cases
  • Pereira J, et al. Cancer 1996
  • Lawlor P, Gagnon B, Mancini I,Pereira J,et al.
    Arch Intern Med 2000

C. Woelk MD
81
Multifocal MyoclonusManagement
  • Stop the current opioid and rotate to a different
    one at 50-75 of the equivalent dose.
  • Allow for adequate breakthrough doses
  • Consider careful hydration
  • Expect resistance from family / staff
  • Interpreting the myoclonus and associated
    symptoms / signs as pain, and increasing the
    original opioid will eventually result in more
    myoclonus and delirium

C. Woelk MD
82
Intractable Symptoms
  • Defining intractable
  • Difficult to manage
  • Resistant to treatment
  • Difficult to alleviate
  • Difficult to control
  • A condition that does not respond to medical
    management

C. Woelk MD
83
Sedation at the End of Life
  • Very common
  • Expected
  • Educate family !

C. Woelk MD
84
Sedation at the End of Life
  • End of life sedation
  • Palliative sedation
  • Terminal sedation
  • Sedation for intractable symptoms

C. Woelk MD
85
Sedation (noun) at the End of Life
  • Very common
  • Expected
  • Educate family !

C. Woelk MD
86
Sedation (verb) at the End of Life
  • End of life sedation
  • Palliative sedation
  • Terminal sedation
  • Sedation for intractable symptoms

C. Woelk MD
87
Sedation at the End of Life when symptoms are
intractable
  • Issues
  • Are symptoms really intractable?
  • Have others been formally consulted?
  • Have details been documented?
  • Are we on a slippery slope?

C. Woelk MD
88
Sedation at the End of Life Medications
  • Usually a combination of
  • Haloperidol or Methotrimeprazine
  • /- Lorazepam or Midazolam

C. Woelk MD
89
Is it time to sedate someone who is imminently
dying?
  • Then its also time to get a consult !

C. Woelk MD
90
Summary
  • Emergencies happen, even in dying individuals.
  • Emergencies may be treated differently in the
    palliative population, with much more of an
    emphasis on symptom management than on attempts
    at reversing the disease process.
  • Communication with the patient and family is
    extremely important for dealing with emergencies.

C. Woelk MD
91
To cure sometimes,to relieve often, to comfort
always.Hippocrates
C. Woelk MD
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