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A GUIDE TO SYMPTOM MANAGEMENT IN
Publication Date: May 2007
Review Date: May 2009
Produced by:Yorkshire Cancer NetworkPalliative Care Group
YORKSHIRE CANCER NETWORK PALLIATIVE CARE GROUP
A GUIDE TO SYMPTOM MANAGEMENT IN
Nausea and Vomiting including:
Syringe Driver Principles, Intestinal
Palliative Care Emergencies:
Spinal Cord Compression, Superior Vena
Caval Obstruction and Hypercalcaemia
The Last Days of Life
Members of the Yorkshire Cancer Network Palliative Care Group produced these guidelines for symptom management. They were updated in 2006 by the specialist registrars in palliative medicine on the Yorkshire Training Scheme and members of the Palliative Care Team at Pinderfields Hospital, MidYorkshire Hospitals NHS Trust. The information reflects a consensus of opinion from specialists working in the field of palliative medicine in hospitals and hospices.
Details are given here of selected widely used drugs. Also see BRITISH NATIONAL FORMULARY (BNF) sections on “Controlled Drugs” and “Prescribing in Palliative Care”. Check BNF for formulations and dose recommendations.
• “The Palliative Care formulary (PCF2)” Second Edition.
Twycross R,Wilcok A, Charlesworth S and Dickman A. Radcliffe Medical Press Ltd 2002 and website http://www.palliativedrugs.
• “The Syringe driver. Continuous subcutaneous infusions in
palliative care”. Second edition. Dickman A Schneider J and Varge J. Oxford University Press 2005
These guidelines are the property of the Yorkshire
Cancer Network Palliative Care Group. It is intended that they be
used by qualified medical and other healthcare professionals as an
information resource. They should be used in the clinical context
of each individual patient’s needs. The palliative care group takes
no responsibility for any consequences of any actions taken as a
result of using these guidelines.
In difficult situations consider seeking advice from the local specialist palliative care team:
SECTION A: PRINCIPLES
Pain is a total, personal experience with physical, psychological, social and spiritual dimensions. Optimal pain management will be compromised if any of these aspects are neglected.
Pain is common in cancer patients, and management can be difficult.
Not all pain experienced by a patient with cancer is caused by cancer itself. Often several pains coexist, and an accurate diagnosis of the cause or mechanism of each pain must precede effective treatment. Regular review is vital for good pain control.
In general successful relief of pain in patients with cancer requires:
Regular, as well as prn (as required), dosage.
Titration of dosage against effect with no rigid upper limit.
Appropriate time interval between doses.
Sufficient dose to prevent return of pain before next dose is due.
Willingness to give strong opioids early when other analgesics fail.
Morphine (or diamorphine) is the mainstay of pain control in advanced cancer, although other analgesics such as paracetamol or a weak opioid may suffice. Follow the “analgesic ladder” (see later).
Give morphine orally if the patient can swallow and absorb the drug. Only consider other routes if the patient has dysphagia, gastric stasis, intractable vomiting or impaired consciousness.
If parenteral opioids are required, a continuous subcutaneous infusion by portable syringe driver or prn (as required) subcutaneous injections should be used. Diamorphine is the drug of choice because its high
solubility allows larger doses to be given in small volumes, but with the current UK wide shortage of diamorphine, morphine for injection may be used.
nausea and vomiting (a common but controllable transient side-effect that usually improves after approximately 5 days),
drowsiness (often dose related and temporary) and
respiratory depression (clinically not a problem if dose is titrated correctly).
Always prescribe laxatives, and consider prescribing prn (as required) or regular anti-emetics. Neither tolerance nor addiction is a significant problem in palliative care practice.
Some pains are only partially opioid-responsive. These include tension headache, post-herpetic pain, muscle spasms, nerve damage/compression, bone pain, visceral distension, tenesmoid pain and activity provoked pain. These may require other measures including co analgesics.
Co analgesics include corticosteroids, anti-depressants, anti-convulsants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs) .
SECTION B: ASSESSMENT AND REVIEW
What is the pain due to?
Be inquisitive. Review and review again. Investigate appropriately. Think of X-ray for pathological fracture or bone metastases; ultrasound or CT scan for deep soft tissue tumours. Remember common non-malignant causes, e.g. arthritis, tension headache, infections including oral thrush.
The analgesic ladder progresses logically from a non-opioid via a weak opioid to a strong opioid. Start at the bottom of the ladder and work up as necessary. Use the drugs at the optimal dose regularly i.e. by the mouth, by the clock, by the ladder. Remember:
Weak opioids include codeine and dihydrocodeine
Cocodamol is available in three strengths containing
Paracetamol and either 8mg, 15mg or 30mg of codeine. In elderly or frail patients a lower strength may be required
Codeine is a pro-drug of morphine. Its analgesic effect is
Paracetamol has a different analgesic effect to opioids
and can provide additional benefit for patients taking strong opioids.
Strong opioids include morphine, diamorphine,
oxycodone, fentanyl, alfentanil, hydromorphone and methadone
SECTION C: RECOMMENDED DRUGS
1. OPIOID ANALGESICS
Formulations availableImmediate release
(would be expected to be effective after 20 minutes and last up to 4 hours)- tablets, liquids,.Modified /slow release
(would be expected to be effective after 4 hours and last for 12 hours or 24 hours, depending on the preparation) - tablets, granules, capsules
Starting regimenStart with 10 mg immediate release morphine 4 hourly if pain not controlled on full dose of regular weak opioid (start with 5 mg 4 hourly if opioid naïve).
Halve these doses i.e. 5 mg or 2.5 mg if patient is elderly or frail. Titrate dose upwards by 30-50% increments to relieve pain or until unacceptable side effects occur. If the patient has renal impairment morphine may accumulate and specialist advice may be required.
Once a stable dose is achieved it is usual to transfer to modified release preparations, e.g. a patient on 10 mg oral morphine immediate release [eg Oramorph] 4 hourly receives a total of 60 mg morphine in 24 hours. This is equivalent to 30 mg 12 hourly of morphine sulphate (modified release) tablets eg MST Continus, Zomorph.
Alternatively a patient who has been taking strong co-codamol regularly could be commenced on modified release morphine sulphate (e.g. MST continus) 20mg bd with immediate release morphine for breakthrough and the dose titrated by 30-50% increments.
Breakthrough painAll patients on modified release morphine should have immediate release morphine available prn (as required) for breakthrough pain, which is 1/6th of their total 24 hour morphine dose e.g. a patient on 30mg MST bd would require 10mg immediate release morphine
Remember to prescribe regular laxatives and prn (as required) anti-emetics and discuss potential side effects of opioids with the patient.
Oxycodone is a strong opioid with properties similar to morphine.
It is available as immediate release oxycodone “Oxynorm” with duration of action 4 hours or slow release oxycodone “Oxycontin” with a duration of action of 12 hours.
It is a useful second line strong opioid for patients who have not tolerated morphine.
Oral oxycodone is about 1.5-2 times more potent than oral morphine. Consult a dose conversion chart when starting oxycodone or ask advice from your local palliative care team or pharmacy.
This section contains information needed for prescribing subcutaneous syringe drivers
It is usual practice across the Yorkshire network to use the
Subcutaneous morphine is 2-3 times more potent than oral morphine
Subcutaneous diamorphine is 3 times more potent than oral morphine
Both diamorphine and morphine can be given as required subcutaneously (s.c.) with duration of action of up to 4 hours. Alternatively they can be given as a continuous subcutaneous infusion via a portable syringe driver.
Starting regimenFor an opioid naïve patient start with 2.5mg sc prn or 5-10mg subcutaneously over 24 hours. For patients previously on oral morphine,•
Divide the total 24 hour dose of oral morphine by 2 or 3 (see local guidelines)
e.g if a patient is on MST 30mg bd, they will require
20-30mg subcutaneous morphine sulphate over 24 hours.
Divide the total 24 hour dose of oral morphine by 3
e.g if a patient is on MST 30mg bd , they will require 20 mg subcutaneous diamorphine over 24 hours.
Breakthrough painIt is extremely important that breakthrough analgesia is
Give 1/6th of their total 24 hour subcutaneous morphine or diamorphine dose e.g for the above example the sc breakthrough dose would be 2.5 - 5mg.
Patients on oral oxycodone who have been intolerant of oral morphine can be converted to a subcutaneous infusion of injectable oxycodone.
To convert to subcutaneous oxycodone divide the total daily dose of oral oxycodone by 2. As for morphine and diamorphine it is important to prescribe breakthrough analgesia which is 1/6th of the total 24 hour dose.
Transdermal preparations are mainly suitable for patients with severe chronic pain already stabilised on other opioids.
Transdermal Fentanyl patches have a 72 hour duration of action.
Transdermal Buprenorphine patches are available as•
Low dose patches which have a duration of action of 7 days.
Higher strength patches, which have a duration of action of 96 hours.
Consult a dose conversion chart when starting transdermal opioids or ask advice from a pharmacist or specialist palliative care practitioner.
Note. Patients will still require prn (as required) immediate release opioids for breakthrough pain.
Other strong opioids
Other strong opioids available include alfentanil, hydromorphone,
and methadone. Please consult with palliative care specialists
before prescribing these.
WHAT IF OPIOIDS DON’T WORK.
a) Is the dose high enough?
If there is a partial response or inadequate duration of pain relief
(i.e. pain returns in under 4 hours) for immediate release oral
morphine or in under 12 hours for modified release morphine
(MR), increase the dose by 30 - 50% increments rather than
shortening the interval between doses. Remember to check that
the prn (as required) dose prescribed is still adequate.
b) Is drug being absorbed?
If there is uncontrolled vomiting, dysphagia or high stoma output
consider alternative routes of delivery (e.g. subcutaneous, rectal,
c) Is pain breaking through with movement or painful
Identify and minimise provoking factors. Consider additional doses
of morphine, consider NSAIDS. Discuss with palliative care team.
d) Are co analgesics required?
Please see below for indications.
e) Who might be able to help?
Don’t be afraid to ask a more experienced colleague for help.
Your hospital palliative care team, local hospice or community
palliative care team will gladly offer advice. Don’t forget
palliative radiotherapy for bone secondaries, often given as a
single treatment. In 5-10% of cases some kind of nerve block will
help (e.g. coeliac plexus block in pancreatic pain) – discuss with
palliative care or pain clinic colleagues.
2. CO ANALGESICS
a) Non-steroidal anti-inflammatory drugs (NSAIDs)
Common indications:- bone pain, musculoskeletal pain, liver
capsule pain, pelvic pain.
Many cancer patients have risk factors for significant
gastrointestinal side effects therefore consider use of proton-
Caution with all NSAIDs in patients with renal impairment and
heart failure. Ibuprofen tablets
Diclofenac tablets or suppositories
Maximum daily dose 150 mgNaproxen tablets or suppositories
500mg – 1g daily in
COX-2 inhibitors should be used with caution.
Common indications: - raised intra-cranial pressure, nerve or spinal
cord compression, liver capsule pain.
Steroid of choice with high anti-inflammatory potency, high solubility and low mineralocorticoid effect (less salt and fluid retention than with some other steroids).
Use at the lowest effective dose for shortest possible time. NB = Dexamethasone 1 mg = Prednisolone 7mg Taper the dose slowly when stopping (not usually necessary if duration of treatment is 1 week or less).
Prescribe doses to be given in the morning to avoid insomnia.
Common indications – neuropathic pain.
Needs to be titrated. Usual dose range 300-1800 mg in divided doses.
Consult BNF for titration regimen. Slower titration is recommended in the frail elderly. Use with caution in renal impairment
Consider asking specialist palliative care or pain team for advice.
Needs to be titrated, check local policy.
Common indications:- neuropathic pain and useful if patient is
10 –75 mg daily. (Lower than usual antidepressant doses).
Start with low dose given at night and gradually increase every 2-5 days if side effects allow. NB Neuropathic pain may take several days to respond to co analgesics.
e) Muscle relaxants
Common indications:- painful muscle spasms
If ineffective discuss with palliative care team.
0.5 – 1 mg oral/sublingual 8-12 hourly / prn
NAUSEA and VOMITING
• Nausea and vomiting can be difficult to control • Causes are often multifactorial and may require more than
e.g gastritis- treat with proton pump inhibitor, oral thrush -treat with antifungals.
• If patient has severe nausea or vomiting, parenteral
• If initial advice below is not effective contact the Palliative
• Prescribe drugs regularly as well as PRN.
(PO or SC)
Metoclopramide 10 - 20 mg
Levomepromazine 6.25 - 12.5 mg
* NB Cyclizine and hyoscine butylbromide are physically incompatible
SYRINGE DRIVER PRINCIPLES
• Can be used for a short period for symptom control or in the
• Inability to swallow or absorb oral drugs, e.g. persistent
vomiting, intestinal obstruction, dysphagia, weakness, unconsciousness.
• NB pain needs to be controlled even when the patient is
• Inadequate pain control is not an indication for syringe driver
use, unless there is reason to believe oral analgesics are not being absorbed. A syringe driver is simply an alternative way of giving the same drugs. This should be explained to the patient and their relatives.
• In palliative care practice it is usual to use a syringe driver
infusion via the subcutaneous route.
• Doses of medication are calculated on the basis of patients’
• Following commencement of a syringe driver it will be several
hours before therapeutic levels are achieved and so consider giving a stat dose of medication equivalent to the normal breakthrough dose.
• Syringe drivers require careful monitoring and should be
prescribed on prescription/ syringe driver charts as per local Trust syringe driver policies.
There are two portable Graseby syringe drivers in common use: MS16A (blue front panel) and MS26 (green front panel). The RATE SETTING between these two models is different and confusion can potentially lead to errors in drug prescribing/administration. Please follow local policy for syringe drivers
SUGGESTED 24HR REQUIREMENTS OR DRUG DOSAGES FOR
SUBCUTANEOUS INFUSIONS VIA SYRINGE DRIVER
Usual 24 hour dose range Comments
5 - 10 mg/24 hours if opioid Seek advice if:
May be increased according and anticonvulsant – short
replace oral anticonvulsants SPCT advice.
All the above drugs can be given as subcutaneous infusions in a syringe driver. Avoid mixtures of more than three compatible drugs if possible.
If patient on fentanyl, hydromorphone, oxycodone or methadone seek specialist advice.
If symptoms are not controlled other regimens may be needed. Seek specialist advice.
Remember to prescribe subcutaneous prn (as required) medication.
Haloperidol and cyclizine are synergistic
Cyclizine and hyoscine butylbromide are incompatible
If using more than one drug in a syringe driver, check compatibilities with pharmacy or SPCT.
INTESTINAL OBSTRUCTION IN ADVANCED CANCER
Intestinal obstruction in advanced cancer is frequently incomplete, intermittent, at multiple sites or due to motility disturbance. There is a high incidence in ovarian and bowel cancer.
Symptoms vary depending on the level and degree of obstruction and may include any or all of the following:
Abdominal X-rays may help but “normal appearances” do not exclude bowel obstruction
Differential diagnosis is constipation but this may also co-exist with bowel obstruction
Passage of flatus stops in complete obstruction.
All patients will require symptom management. Surgical intervention should also be considered early in appropriate cases (see below).
Selecting patients who are likely to benefit from a surgical procedure (e.g. bowel resection or by-pass +/- stoma formation) is difficult. These decisions are best made with an experienced surgical colleague and careful discussion with the patient. Patients likely to benefit are those with no other life threatening disease and single site obstruction. Other factors to consider include patient co-morbidity, nutritional status and options for further treatment such as chemotherapy.
With appropriate symptomatic treatment patients may survive several weeks or occasionally months. Good symptom management can usually be achieved and greatly improves quality of life. Medication should generally be given by sub-cutaneous injection or continuous sub-cutaneous infusion.
IV Fluids and NG tube
These regimens are indicated while surgery is being considered or as a short-term intervention but are rarely appropriate for long-term management
Nausea and vomiting
Set realistic goals. Nausea can usually be reduced significantly but vomiting may continue once or twice daily.
Give anti-emetics parenterally and regularly. Subcutaneous infusion is often helpful (see nausea and vomiting guidelines).
Stop stimulant laxatives and prokinetic drugs, e.g. metoclopramide
Use antispasmodics (hyoscine butylbromide 60 - 180mg/24 hours)
Dull aching pain
Note: Dexamethasone, high dose metoclopramide and octreotide
may also be used under specialist advice.
Nutrition and IV Fluids
IV fluids and T.P.N. are rarely necessary.
Oral intake of food and drink can continue for the patient’s enjoyment and is often surprisingly well tolerated - the patient will decide if the risk of vomiting outweighs the pleasure of eating.
Patients with a high obstruction without other life-
threatening complications require special consideration regarding symptom management, hydration and nutrition. e.g venting gastrostomy, TPN may be considered in individual cases
Constipation is very common in the hospitalised patient due to a combination of factors including immobility, reduced food and fluid intake, drugs, bowel pathology and sometimes hypercalcaemia. Assess for these contributing factors and treat as appropriate. Diagnosis is usually made on the basis of history and examination. Abdominal X-ray is rarely required.
Guidelines on the use of laxatives in constipation
Assess cause and treat where possible.
Movicol (1-2 sachets bd up to 8/day) is the drug of choice in patients who are able to drink sufficient volumes of liquid.
A combination of senna and lactulose can be effective, but has more side effects.
For patients with malignant disease codanthramer or codanthramer strong are effective and are smaller volume preparations. NB patients on codanthramer need to be warned that danthron stains urine red and can cause contact dermatitis. Do not use in incontinent patients
Avoid stimulants such as codanthramer and senna if colic is present.
In complete bowel obstruction do not prescribe laxatives without seeking advice.
Ask the patient whether they prefer laxative in liquid or tablet form.
If bowels haven’t moved in 3 days, do a rectal examination and follow local guidelines on rectal measures.
Definition of dyspnoea:
uncomfortable awareness of
Dyspnoea occurs very commonly in advanced cancer, cardiorespiratory and neurological disease.
Look for reversible causes as listed below.
Is dyspnoea of sudden onset?
Diamorphine/ morphine 5mg s.c./i.v.
Has dyspnoea arisen over several days?
Dyspnoea of more gradual onset
Congestive cardiac failure Diuretics, digoxin, ACE inhibitorsAnaemia
( esp. bleomycin), or lung RT. Palliative
Dexamethasone 8-12mg o.m. Stop
Reversal of cause of dyspnoea inadequate or impossible
– Palliative Management
Dyspnoea is frightening to patient, family and staff. Reassurance and explanation are vital parts of the treatment whatever the cause.
Modification of lifestyle, breathing retraining and relaxation may be beneficial if instituted early enough.
Consider referral to physiotherapist.
A table fan directed onto the face often eases dyspnoea.
Good mouthcare is important if there is persistent mouth breathing.
Humidified oxygen may help acute dyspnoea but should be used alongside other measures and its use reviewed regularly.
Long term oxygen therapy for chronic respiratory illness should only be instigated by respiratory physicians.
Many patients requiring palliation for breathlessness will not benefit from oxygen therapy.
Drugs to consider
All drugs for symptomatic relief of dyspnoea are respiratory sedatives. When prescribed, their use should be monitored carefully. In the context of distressing dyspnoea in the terminal stages of illness the benefits usually out-weigh the risks.
Oral morphine (immediate release) 2.5mg 4 hourly. Gradually titrate dose upward according to response or until unacceptable side-effects occur.
If already taking strong opioid for analgesia contact palliative care team for advice.
Lorazepam 0.5mg-1mg sub-lingual may give rapid relief during panic attacks.
For longer-term management consider oral diazepam 2mg once at night or twice daily. Midazolam 2.5mg initially subcut may benefit patients that cannot tolerate oral/sub-lingual route.
These drugs can be continued in the terminal phase. See section of ‘Last days of Life’.
PALLIATIVE CARE EMERGENCIES
SPINAL CORD COMPRESSION
Spinal cord compression is a well recognised complication of metastatic cancer
This is a catastrophic event leading to paralysis below the level of the compression, urinary retention and faecal incontinence
If treated early these problems can usually be prevented or at least partially reversed.
It is a clinical diagnosis requiring IMMEDIATE
with an orthopaedic, neurosurgical or oncology team
concerning appropriate investigations and treatment.
Back pain or nerve root pain either unilateral or bilateral, particularly if associated with alteration in gait
May be aggravated by movement, coughing or lying flat
May precede other symptoms by up to 6 weeks
May be absent in approximately 10% of patients
Motor weakness below level of lesion. This may be rapid or slow in onset and can be subtle in the early stages. Descriptions of perceived changes in strength are important.
Often precedes objective physical signs, e.g. “ I feel like I am walking on cotton wool”
Urinary retention often develops insidiously.
The absence of signs does not
exclude early spinal cord
compression. Investigations should be considered on the basis of
history alone in a patient who is at risk.
Change in sensation below level of lesion [not always complete loss of sensation]
Reflexes – absent at level of lesion – increased below it
NB: Sensory and reflex changes may occur secondary to other disease processes or previous neurotoxic chemotherapy.
Whole spine MRI - investigation of choice and shows full extent of disease.
Plain X-ray films – identify vertebral involvement in 80% of those with extradural compression but is of limited use in determining the extent of spinal involvement.
– can be commenced if there is strong clinical suspicion
of cord compression, and no contraindications pending definitive
investigations. Give dexamethasone 16mg/stat then once daily
in the morning. May give short term improvement while
arrangements are being made for investigations and treatment.Surgery
– discuss surgical treatment with neurosurgeon or
orthopaedic surgeon in the following situations:
No previously established tissue diagnosis
Discuss with oncologist regarding:Radiotherapy
– if patient is unsuitable for surgery, urgent referral
for radiotherapy unless prognosis deemed to be only a few days. Chemotherapy
– may be indicated in treatment of some tumours.
SUPERIOR VENA CAVAL OBSTRUCTION
• Most commonly seen in lung cancer• Consider lymphoma, particularly in young patients• Regard as emergency as patient’s condition may deteriorate
SYMPTOMS AND SIGNS
1. Swelling of the face and neck2. Feeling of fullness in the head3. Dyspnoea, worse on lying flat4. Non pulsatile raised jugular venous pulse [JVP]5. Dilated anterior chest wall veins
Discuss with radiologist regarding local policy:• Chest X-ray• Thoracic CT
Vascular stenting is usual treatment of choice although radiotherapy or chemotherapy may be good alternatives.
Chemotherapy: may be treatment of choice in lymphoma and small cell lung carcinoma (if diagnosis previously established)
The evidence for the use of steroids as a holding measure before definitive treatment is lacking. Where used this should be for a limited duration.
Discussion with local respiratory team/oncologist is recommended.
Recurrent superior vena caval obstruction
Radiotherapy may be considered. Vascular stent may be replaced. Thrombolysis may be considered if a stent is blocked by thrombus.
Treatment often gives useful symptomatic relief.
In untreatable SVCO end of life measures are required
• Affects up to 10% of patients with cancer• Most commonly seen in breast, lung, renal carcinoma and
• Consider in unexplained nausea, vomiting or confusion• Patient may not have demonstrable bone metastases• May develop insidiously
SYMPTOMS AND SIGNS
• Severity of symptoms is more related to the speed of rise of
serum calcium rather than the absolute calcium level.
• Early symptoms are non-specific: lethargy, malaise, anorexia• Polyuria, thirst, dehydration• Nausea and vomiting, constipation• Confusion• Later features: drowsiness, fits, coma
Serum calcium (corrected for serum albumin)Urea and electrolytesCalcium below 3.0mmol/l – treat if symptomatic, monitor if asymptomaticCalcium above 3.0mmol/l – treatment usually neededCalcium above 4.0 mmol/l – seek advice urgently
Rehydration – using 0.9% sodium chloride. Average requirement is 2-4 litres (beware of fluid overload in patients with comorbidity). Correct hypokalaemia.
Bisphosphonate – eg Pamidronate (Dose varies depending on the level of hypercalcaemia ) or zoledronic acid 4mg iv over 15-30 minutes. Give IV infusion in 0.9% sodium chloride after rehydration.
Bisphosphonates are associated with osteonecrosis of the jaw which is untreatable. Patients should have a dental assessment if repeated doses of bisphosphonates are anticipated but this should not delay treatment for hypercalcaemia
Discontinue IV fluids when oral intake adequate. Recheck calcium level in 5 to 7 days or earlier if symptoms have not improved. Repeat bisphosphonate dose if calcium has not come down to normal after one week.
Average duration of response is 3-4 weeks.
Prognosis depends on the underlying pathology.
Ensure patient is followed-up after treatment.
For recurrent hypercalcaemia consider maintenance oral bisphosphonate or intermittent IV bisphosphonate. Patients should have a dental assessment and the dental practice should be informed that they are on bisphosphonates to minimise the risk of osteonecrosis of the jaw.
Resistance to treatment with bisphosphonates is a poor prognostic sign.
THE LAST DAYS OF LIFE
It is desirable to recognise when death is imminent. This allows withdrawal of unnecessary treatments and preparation of the patient and family/carers for death. This phase can be difficult to recognise. It is often heralded by a more rapid deterioration in the patient’s general condition. Consider use of the integrated care pathway for the dying if available. The following symptoms and signs in patients may indicate that the prognosis is short:
• Profound weakness• Confined to bed for most of the day• Drowsy for extended periods• Disorientated • Severely limited attention span• Loss of interest in food and drink• Too weak to swallow medication
1. Sensitively check the awareness of patient and family/carers.
2. Negotiate appropriate treatment with the patient. The wishes
of the family/carers should be considered but not allowed to override those of the patient.
3. Negotiate the place of care – home, hospice, hospital etc.
taking into account the needs and wishes of the patient and the family/carers.
4. Professional carers may need to acknowledge and share their
own feelings. Mutual support and teamwork are important.
5. Physical, psychological and spiritual, practical and legal issues
6. Level 6/Critical care funding form or equivalent needs to be
What nursing care is needed?
• If a patient is to be discharged home from hospital ensure the
distric nurse and community palliative care team are aware and telephone the general practitioner.
• Adequate day and night nursing support needs to be
• Ensure the patient is not left alone for long periods.
• Involve family/carers in practical care as much as they wish.
• Treat dry mouth with good regular mouth care (minimum
• Immobility and pressure areas - bed, mattress, positioning
• Continence - consider catheter, convene, pads.
• Bowel care - only if constipation is causing discomfort.
What about food and fluids?
Regular artificial hydration does not usually contribute to a dying patient’s comfort. Remember patients are dying from their disease and not from lack of food or fluids. Dry mouth is usually related to medication, mouth breathing and/or oxygen therapy and can be relieved by good mouth care (i.e. keeping oral mucosa and lips clean and moist).
Possible benefits of withdrawing artificial hydration/nutrition include:
• Reduced vomiting and incontinence.
• Reduced barriers between patient and family/carers.
• Reduced painful venepuncture.
What about medication?
Only continue medication needed for symptom management. If the oral route is not appropriate the subcutaneous route or the rectal route can be used.
Consider stopping some of the following when the patient is no longer able to swallow:
• Vitamins/iron• Hormones• Anticoagulants• Corticosteroids• Antibiotics• Antidepressants• Cardiovascular drugs• Anticonvulsants (used for pain)
This can occur at the end of life but there may be a precipitant, therefore look for evidence of:• Physical discomfort – pain related to underlying condition,
urinary retention, faecal impaction or new event e.g. haemorrhage, malfunctioning syringe driver.
• Respiratory distress – dyspnoea, cough, tracheal obstruction.
• Neurological problems – fits, hallucinations, myoclonic jerks,
motor restlessness. Remember any of these may be caused by drugs (including opioids and antiemetics).
• Psychological distress (see below).
If no reversible precipitating factors midazolam is the drug of choice (see syringe driver section)
This is a rattling noise produced by the movement of secretions in
the upper airways in patients who are too weak to expectorate
effectively. Relatives and carers may find this distressing. It is
important to explain to the relatives/carers that this is unlikely
to be causing distress to the patient. Prompt drug treatment is
• Repositioning of the patient and postural drainage may help.
• Antisecretory drugs can be used (see syringe driver section ).Do not attempt resuscitation orders
If a patient is in the last days of life resuscitation is unlikely to benefit the patient. The resuscitation status of the patient should
be discussed within the clinical team and documented as per local policy. It is good practice to inform the patient’s carers that the focus of care is on palliation.
Distressing terminal events
Events such as haemorrhage, fits or tracheal obstruction are unusual and can often be anticipated and a management plan discussed with nursing staff in advance. Prescribe appropriate PRN medication (eg diamorphine or morphine and midazolam) to relieve distress and sedate if necessary. Seek advice from palliative care team if unsure.
Psychological and spiritual care of patient and family
• Encourage open communication and explore fears and
• Facilitate expression of emotions• Involve children and those with learning disabilities. • Remember spiritual care and religious needs (offer to contact
chaplain, priest, rabbi etc if appropriate).
• Identify those at increased risk in bereavement:• previous multiple losses or recent losses• ambivalent relationship• dependant children involved• bereaved parent• previous psychological problems or substance abuse• people living alone or feeling unsupported • Seek advice from colleagues and relative’s GP [with their
permission], if one or more of these risk factors are present.
Practical and legal aspects to attend to after death
Arrangements may vary depending on place of death and the role of the bereavement co-ordinator (where one exists).
• Warn relatives when Coroner’s referral might be necessary (eg
mesothelioma). Preferable to do this before the death.
• Ensure prompt provision of death certificate• Ensure patient’s GP is informed within 24 hours• Ensure hospital appointments are cancelled and hospitals/
consultants involved with the patient’s care are informed
Lymphoedema is a chronic progressive swelling due to the inability of the lymphatic system to maintain normal tissue homeostasis. This results in an accumulation of protein rich fluid in the subcutaneous tissues. Lymphoedema is one form of chronic oedema. In patients with cancer lymphoedema is usually secondary to the underlying cancer or previous cancer treatment.
• Oedema• Chronic inflammation• Excess fibrosis • In the early stages of lymphoedema pitting is demonstrated.
With time this feature is lost due to the oedema having a high protein content.
Where available, patients should be referred to specialist lymphoedema clinics. The core treatment elements are:• Skin care – Keep skin clean and moisturised with non-
perfumed emollient (e.g. aqueous cream, diprobase [proprietary] )
• Compression / support• Movement and exercise• Simple lymph drainage, self-massage techniquesAvoid affected limb for any medical procedure, e.g. injection, venepuncture, blood pressure measurement.
MANAGEMENT OF CELLULITS IN LYMPHOEDEMA
(Consensus document from the Lymphoedema Support
Network and British Lymphology Society January 2006)
Treat early1. Oral amoxicillin 500mg t.d.s. for minimum 14 days (clindamycin
2. If evidence of Staph Aureus infection add in flucloxacillin3. Avoid compression garments during acute attack
Acute infection is usually painful; review analgesics
If patient develops systemic symptoms IV antibiotics may be required; seek specialist advice.
Antibiotic prophylaxis is needed if patient has had 2 or more attacks of cellulitis per year. Penicillin V 500mg daily ( erythromycin 250mg daily if penicillin allergic ) first line. Please refer for specialist advice.
FURTHER INFORMATION The Lymphoedema Support Network - www.lymphoedema.org/lsn
Yorkshire Cancer Network Palliative Care Group
Telephone: 0113 3924033 · Fax: 0113 3924131 · www.ycn.nhs.uk
Hoodia Hoodoo Teacher Handout: Correlation to National Standards National Social Studies Standards VI. Power, Authority, and Governance Social studies programs should include experiences that provide for the study of how people create and change structures of power, authority, and governance, so that the learner can: • b. explain the purpose of government and analyze h
F, NUTR_DEF 2011.08.29 2011.07.25 FNUTRDEF.PRG #146 NUTR_NO,UNITS,TAGNAME, NUTRDESC, .num_dec , SR_ORDER You may select any of these nutrients for research purposes The values will be as per the USAD REL 24 TABLES 203 , g PROCNT PROTEIN .2 ,600 204 , g FAT TOTAL LIPID (FAT) .2 ,800 205 , g CHOCDF CARBOHYDRATE, BY DIFFERENCE .2 ,1100 207 , g ASH ASH .2 ,1000 208 , kcal ENERC_KCAL ENERGY .0 ,300 20