Cancer and palliative care
Principles of cancer care [link]
Surgery for cancer [link]
Palliative care in general practice [link]
Pain and general debility [link]
Anorexia, nausea and vomiting [link]
Other GI problems [link]
Skin, neurological, and orthopaedic problems [link]
Respiratory problems [link]
Haematological and vascular problems [link]
Psychiatric problems [link]
The last 48 hours [link]
Principles of cancer care
If cancer is suspected as a result of signs or symptoms locally at the original site or at distant sites, an accurate and comprehensive assessment of both the patient and the disease must be undertaken before a treatment decision is reached. Treatment can be:
• Radical Curative intent—surgery and/or drug/radiotherapy.
• Adjuvant Given after surgery when micrometastatic disease is suspected—decision to proceed is based on the likelihood of relapse.
• Palliative When cure is not possible ( p.[link]).
Assessment of the tumour
• Histological nature of the tumour Tissue of origin, cancer type (e.g. adenocarcinoma, squamous cell cancer), degree of differentiation, and tumour grade. High-grade poorly differentiated tumours tend to have a poorer outcome than low-grade well-differentiated tumours.
• Biological behaviour of the tumour Tumour markers produced by cancers may be a useful adjunct to histological classification and staging and can be used to influence and monitor efficacy of treatment (Table 28.1). Tumour markers can be ↑ in non-malignant conditions.
• Anatomical extent of the tumour Usually determined through a combination of clinical, radiological, biochemical, and surgical assessment. Routine blood tests including liver function tests and bone profiles may also indicate the presence of metastases.
Table 28.1 Tumour markers and associated conditions
GI tract cancers (particularly colorectal cancer)
Germ cell cancers (not pure seminoma)
Open neural tube defects
Germ cell cancers
Choriocarcinoma and hydatidiform mole
Benign prostatic hypertrophy
Prostate instrumentation (including rectal examination)
Acute urinary retention
Staging allows the plan of treatment to be made.
Widely used classification of tumours. Exact criteria for staging depend on the primary organ site:
• T—Primary tumour. Graded T1–T4 with increasing size of primary.
• N—Regional lymph nodes. Advancing nodal disease is graded N0–N3.
• M—Presence (M1) or absence (M0) of metastases.
• Stage 1 Clinical examination reveals a tumour confined to the primary organ. The lesion tends to be operable and completely resectable.
• Stage 2 Clinical examination shows evidence of local spread into surrounding tissue and first draining LNs. The lesion is operable and resectable but there is a higher risk of further spread of disease
• Stage 3 Clinical examination reveals an extensive primary tumour with fixation to deeper structures and local invasion. The lesion may not be operable and may require a combination of treatment modalities.
• Stage 4 Evidence of distant metastases beyond the site of origin. The primary site may be surgically inoperable.
• Patient’s performance status The Eastern Co-operative Oncology Group (ECOG) Performance Status Scale is widely used (Table 28.2). Patients with ECOG score >2 are usually deemed unsuitable for most chemotherapy interventions
• Mortality, morbidity, and efficacy of the therapeutic procedure
• Patient preference
Table 28.2 ECOG Performance Status Scale
Fully active; able to carry on all activities without restriction
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature
Ambulatory and capable of all self-care; confined to bed or chair 50% of waking hours
Capable of only limited self-care; confined to bed or chair 50% or more of waking hours
Completely disabled; cannot carry on any self-care; totally confined to bed or chair
As published in Oken MM, Creech RH, Tormey DC et al. Toxicity and response criteria of the Eastern cooperative oncology group. Am J Clin Oncol (1982) 5: 649–55, with permission from the Eastern Cooperative Oncology Group, Robert Comis MD, Group Chair.
The GP’s role
Treatment of cancer is increasingly successful but also increasingly complex. It is largely a specialist activity, but the role of the GP is important at this time, even if peripheral.
• Keep in touch with the family and up to date with treatment—provide support (e.g. advice on benefits/local services), preventive care (e.g. flu vaccination for patients and/or carers), and general medical care.
• Liaise with the secondary care teams involved, and provide continuity if care is passed from one specialist team to another.
• If the patient does not survive, provide ongoing support to the family.
Surgery for cancer
Surgery has 3 main roles in cancer management.
Diagnosis and staging
Advances in imaging and laparoscopic techniques have dramatically reduced the number of patients requiring open surgery to confirm a cancer diagnosis. However, surgical staging remains important in the following.
• Breast cancer—‘sentinel’ axillary node biopsy is needed to accurately predict the state of nodal disease.
• Ovarian cancer—tumour deposits on the peritoneal surface are poorly visualized with conventional imaging. Direct visualization is required using laparotomy or laparoscopy.
• Certain abdominal malignancies—laparoscopic assessment of the extent and spread of tumour is performed prior to major resection.
Surgery with curative intent is dependent on complete resection of the tumour with a margin of normal tissue. Local control of tumours with a propensity to spread to lymph nodes may be improved with resection of the draining group of nodes, e.g. vulval tumours. However, even if the tumour was completely resected, surgery can still fail to cure either as a result of:
• Development of metastatic disease as a result of the presence of micro-metastatic deposits unidentifiable at the time of surgery.
• Development of local relapse as a result of inadequate margins. Surgical margins can be limited by patient-related factors (e.g. only a partial lobectomy may be possible in patients with lung cancer because of poor underlying respiratory function) or by tumour-related margins (e.g. invasion of the tumour into vital structure such as the aorta).
Surgery may be curative in a limited number of tumours with metastases. However, this is much less common, requires careful patient selection, and is best performed by a specialist team. Circumstances in which curative surgery may be offered include:
• Isolated brain metastases from breast cancer with a long disease-free interval.
• Liver metastases from colorectal cancer.
• Pulmonary metastases from osteosarcoma or soft tissue sarcoma.
Surgery can be effective in achieving good symptom control in the palliative setting, but decision to proceed must be carefully considered, particularly as patients may have limited life expectancy, poor performance status, and rapid tumour progression. Ideally, such decisions should be multidisciplinary and involve surgeons specialized in oncology and experienced in palliative management (Table 28.3).
Table 28.3 Situations in which palliative surgery should be considered
Cancers causing obstructive symptoms e.g. bowel, ovary, ureter, bronchus
Surgery to relieve the obstruction may be warranted even if the underlying disease is incurable with locally advanced disease or distant metastases.
Bowel obstruction—this occurs most commonly in patients with colonic or ovarian cancer.
Oesophageal or bronchial obstruction—laser therapy of an intra-luminal mass may restore the lumen.
Obstructive hydronephrosis—nephrostomy or ureteric catheters may relieve the obstruction.
Placement of a stent—may help to relieve the symptoms of dysphagia, dyspnoea, jaundice, and large bowel obstruction.
Fistulae, often arising as a result of pelvic tumours or as a side effect of radiotherapy, can be associated with distressing malodours and excessive discharge.
Surgery may provide excellent palliation but may not be useful in those with multiple sites of fistulae or rapidly advancing intra-abdominal disease where life expectancy is limited.
Radiological and/or endoscopic stent placement can relieve obstructive jaundice secondary to extrinsic pressure from lymph nodes on the biliary system or intrinsic pressure from cholangiocarcinoma or pancreatic carcinoma.
Complications: infection or blockage necessitate replacement.
Surgical relief by choledochoenterostomy avoids the problems associated with stents and may be indicated in a small minority with excellent performance status and slowly growing disease.
Spinal cord compression and brain tumours
Urgent referral for neurological assessment for decompressive surgery is indicated for confirmed spinal disease or operable brain tumours.
A wide range of endoscopic techniques have been developed to stop bleeding from benign and malignant causes, including sclerotherapy with adrenaline, laser coagulation, and radiological embolization.
These techniques may avoid the need for major surgery in patients who have a limited life expectancy.
Prophylactic fixation of a long bone may reduce either pain and/or the risk of pathological fracture in patients with:
• Lesions in weight-bearing bones
• Destruction of > 50% of the cortex
• Pain on weight-bearing
• Lytic lesions
In all cases fixation should be followed by radiotherapy to control growth and promote healing.
If the expected morbidity of the procedure is low, surgical debulking of large slowly growing tumours can reduce pain.
Neurosurgical approaches such as cordotomy are only rarely considered.
Chemotherapy is the use of chemical agents in the cure or palliation of malignant disease.
• Antibiotics, e.g. bleomycin
• Alkylating agents, e.g busulfan
• Antimetabolites, e.g. methotrexate, 5-fluorouracil
• Alkaloids, e.g. vincristine
• Platinum derivatives—DNA intercalating agents, e.g. cisplatin
• Enzymes, e.g. asparaginase
• Hormones, e.g. sex hormones, corticosteroids
• Biological agents, e.g. interferon, monoclonal antibodies (e.g. rituximab)
• Others, e.g. hydroxycarbamide, retinoids.
These agents work in a variety of ways to inhibit tumour growth and/or cause tumour cell damage. Normal cells may be damaged at the same time as tumour cells, resulting in the high levels of toxicity experienced by patients.
Choice of agent
depends on known activity of the agent, cost, and patient factors. It is a specialist decision.
Types of tumour
Response to chemotherapy depends on type and grade of tumour being treated. Broadly tumours can be divided into:
• Those likely to respond—leukaemia, lymphoma (Hodgkins and intermediate/high grade non-Hodgkin’s), testicular tumours, small-cell lung cancer, embryonal tumours, choriocarcinoma, ovarian cancer, sarcoma, breast cancer, prostate cancer.
• Those that may respond—low-grade non-Hodgkin’s lymphoma, GI cancer, brain/CNS tumours, melanoma, bladder cancer, uterine cancer.
• Those unlikely to respond—non-small-cell lung cancer, renal cancer, pancreatic cancer, head and neck cancer, cervical cancer, liver cancer
Often different chemotherapeutic agents are combined to increase their chances of effect. Agents acting in different ways may potentiate each other’s actions, and using combinations reduces the risk of resistance (if one agent does not have any effect, another may). Choosing agents with different side-effect profiles reduces cumulative toxic effects.
Particularly useful for cytotoxic drugs. Intermittent treatment exploits the difference in recovery rates between normal and malignant tissues. Gaps between cycles of treatment allow normal tissue (particularly the immune system) to recover, but the malignant tissue does not recover to such a large extent (Figure 28.1). The population of malignant cells diminishes relative to the normal cells with each cycle.
Given to prevent relapse after primary treatment of a non-metastatic tumour for which relapse rate is known to be high. An example is adjuvant chemotherapy for breast cancer.
Neutropoenic sepsis is defined as fever ≥38.0°C for ≥2h when the neutrophil count is <1.0 × 109/L. Causes:
• Chemotherapy (most common cause).
• Radiotherapy—if large volumes of bone marrow are irradiated, e.g. pelvic radiotherapy.
• Malignant infiltration of the bone marrow, e.g. prostate/breast cancer.
Risks of neutropoenia
Bacterial and fungal infection. Risk of infection ↑ sharply as neutrophil counts fall below 1.0 × 109/L, with greatest risk at counts <0.1 × 109/L. Neutropoenia for >5d is a further risk factor.
Presentation and primary care management
Symptoms/signs may be minimal—have a high index of suspicion. Neutropoenic septic patients can deteriorate rapidly and become hypotensive or moribund within hours. Early referral for investigation and specialist management is critical.
• If a high-risk patient complains of chills, fever, rigors, sore throat, or generalized aches, check an urgent FBC.
• Mouth ulcers and ↑ fatigue can be signs of neutropoenia.
Development of fever in a patient with neutropoenia is a medical emergency caused by infection until proven otherwise.
Mechanism of action
Ionizing radiation damages cells. Radiotherapy aims to deliver a dose of irradiation to an area which allows normal tissues, but not the cancer, to recover from the damage.
Delivery of radiotherapy
may be used alone or with chemotherapy. Once the maximum dose of radiotherapy has been received by any area, that area cannot usually be irradiated again.
• External beam—external source of ionizing radiation (e.g. gamma rays) is aimed at a target point in the body. Patients may be immobilized, e.g. with special boards/moulds, to ensure delivery of treatment to the correct place. Can be single dose (e.g. for palliative reasons) or fractionated into several doses spread over weeks. Fractionation ↑ effect.
• Brachytherapy Delivery of radiation by placing a radioactive source within or close to the malignancy, e.g. caesium-137 in the uterus.
Table 28.4 Managing post-radiotherapy skin reactions
Aqueous cream bd to delay onset of reaction
Skin slightly pink or red
Aqueous cream tds or prn
Tender or bright erythema
Skin red, dry, and scaly— some itch and tingling
Frequent aqueous cream (qds or prn)
Diprobase® cream or soft white paraffin (avoid excess build-up)
Hydrocortisone cream may be used sparingly on itchy areas. Review after 7d—discontinue if the skin breaks
Patchy moist desquamation, oedema
Skin inflamed with patches of epidermis broken down and moist
Apply hydrogel dressings to moist areas with appropriate 2° dressing; e.g Surgipad® or foam dressing
Apply aqueous cream to other parts of the field
Confluent moist desquamation
Epidermis blisters and sloughs; underlying dermis exposed and sore; oozing of serous fluid
Apply hydrogel or foam dressing suitable for the amount of exudate
Swab and treat with oral antibiotics (e.g. flucloxacillin 500mg qds) if any signs of infection
Reaction may continue for several weeks post treatment. Continue with use of aqueous creams until skin returns to normal.
If RTOG 2B/3 apply principles of moist wound healing as above or (if patient is not allergic to silicone) a silicone dressing.
If infection is suspected apply silver impregnated dressings or silver sulfadiazine cream.
* RTOG stands for radiotherapy and oncology group.
Treatment may be
• Curative, e.g. childhood tumours, lymphoma, seminoma, head and neck tumours, bladder cancer, squamous/basal cell skin cancer.
• Adjuvant pre-operatively to ↓ size/extent of otherwise inoperable tumours, or post-operatively to treat microscopic foci remaining after tumour removal (e.g. in treatment of breast cancer).
• Palliative for control of distressing symptoms. Only symptomatic sites of disease are targeted, e.g. bone metastases, haemorrhage, obstruction of a viscus, neurological complications, fungating tumours.
Table 28.5 Non-skin side effects of radiotherapy
Associated with radiotherapy to the head/neck.
Advice: visit the dentist prior to treatment; avoid smoking, alcohol, and spicy foods; rest voice when radiotherapy reaction becomes established.
Consider treatment with: normal saline/bicarbonate mouthwashes, antiseptic mouth washes (e.g. chlorhexidine, though alcohol may sting), soluble aspirin (can be gargled) or paracetamol, benzydamine, topical local anaesthetics (e.g.xylocaine gel), topical steroids (e.g. triamcinolone in dental paste, hydrocortisone pellets), coating agents (e.g.sucralfate).
If insufficient fluid/food intake, consider nutritional support via NG tube and/or referral for gastrostomy (if weight loss >10%).
May result from thoracic radiotherapy. Avoid smoking, spirits, and spicy food. Consider treatment with antacid, sucralfate, soluble paracetamol or aspirin, NSAID po/PR.
Nausea and vomiting
Radiotherapy to the abdomen often causes nausea as a result of serotonin release. Consider prophylactic antiemetic therapy with a serotonin inhibitor, e.g. ondansetron.
Frequently accompanies abdominal/pelvic radiotherapy.
Management: dietary modification (e.g. ↓ dietary fibre) may help. Supply with loperamide—4mg initial dose then 2mg every 2h until symptoms settle (4mg every 4h at night). Proctitis may accompany rectal/prostatic irradiation. Treat with rectal steroids.
Acute pneumonitis can develop 1–3mo after treatment and is associated with a fever, dry cough, and breathlessness. Differential diagnosis: pneumonia
Investigation: CXR—shows lung infiltration confined within the treatment volume..
Management: steroids—start with 40mg od prednisolone and reduce over a period of weeks as improvement occurs.
Pulmonary fibrosis may occur >12mo after treatment.
Can occur after cranial irradiation, especially if no surgery to the tumour. Steroid dose is ↓ after completion of radiotherapy. Consider ↑ dose again.
Occurs within a few weeks of brain irradiation.Presents with nausea/vomiting, anorexia, dysarthria, ataxia, profound lethargy. Treatment is supportive. Recovery may occur spontaneously.
Palliative care in general practice
Any man’s death diminishes me because I am involved in mankind.
Devotions, Meditation 17, John Donne (1572–1631)
Palliative care starts when the emphasis changes from curing the patient and prolonging life to relieving symptoms and maintaining well-being or ‘quality of life’. GPs have 1–2 patients with terminal disease at any time and get more personally involved with them than with any others.
The problems arising are a complex mix of physical, psychological, social, cultural, and spiritual factors involving both patients and carers. To respond adequately, good lines of communication and close multidisciplinary teamwork are needed. Local palliative care teams are invaluable sources of advice and support, and frequently produce booklets with advice on aspects of palliative care for GPs.
Symptom control must be tailored to the needs of the individual. A few basic rules apply:
• Carefully diagnose the cause of the symptom.
• Explain the symptom to the patient.
• Discuss treatment options.
• Set realistic goals.
• Anticipate likely problems.
• Review regularly.
The Gold Standards Framework
aims to improve quality and of palliative care provided by the primary care team by developing practice-based organization of care of dying patients. The framework focuses on: optimizing continuity of care, teamwork, advanced planning (including out-of-hours), symptom control, and patient, carer, and staff support. Evaluation data show that the framework ↑ the proportion of patients dying in their preferred place and improves quality of care as perceived by the practitioners involved.
Death is the natural end to life—not a failure of medicine.
Although drugs can usually be administered by mouth to control the symptoms of terminal illness, occasionally that is not possible. Portable syringe drivers give a continuous subcutaneous infusion and can provide good control of symptoms with little discomfort or inconvenience to the patient. Indications:
• The patient is unable to take medicines by mouth because of nausea and vomiting, dysphagia, severe weakness, or coma.
• There is bowel obstruction and further surgery is inappropriate.
• The patient does not want to take regular medication by mouth.
Mixing drugs in syringe drivers
Provided that there is evidence of compatibility, drugs can be mixed in syringe drivers. Diamorphine can be mixed with:
• Hyoscine hydrobromide
• Hyoscine butylbromide
Common problems with syringe drivers
• If the syringe driver runs too slowly Check that it is switched on; check the battery; check the cannula is not blocked.
• If the syringe driver runs too quickly Check the rate setting.
• Injection site reaction If there is pain or inflammation, change the injection site.
Table 28.6 Drugs that can be used in syringe drivers
Nausea and vomiting
Levomepromazine 5–200mg/24h (causes sedation in 50%)
Cyclizine 150mg/24h (may precipitate if mixed with other drugs)
Octreotide 300–600 micrograms/24h (consultant supervision)
Hyoscine butylbromide 20–60mg/24h
Hyoscine hydrobromide 0.6–2.4mg/24h
Restlessness and confusion
Midazolam 20–100mg/24h (and fitting)
Diamorphine: ⅓–½ dose oral morphine/24h
Morphine: ½–⅔ dose of oral morphine/24h
Oxycodone: half dose oral oxycodone/24h
Subcutaneous infusion solution should be monitored regularly both to check for precipitation (and discoloration) and to ensure the infusion is running at the correct rate.
Incorrect use of syringe drivers is a common cause of drug errors.
Pain and general debility
Pain control is the cornerstone of palliative care. Cancer pain is multifactorial—be aware of physical and psychological factors.
Principles of pain control
Management of specific types of pain
Table 28.7 Management of specific types of pain
Type of pain
Pain of short duration
e.g. dressing changes—try a short-acting opioid, e.g. fentanyl citrate 200 micrograms lozenge sucked for 15min prior to procedure or breakthrough dose of oral morphine 20min prior to procedure.
Weakness, fatigue, and drowsiness
Almost a universal symptom.
• Drugs—opioids, benzodiazepines, steroids (proximal muscle weakness), diuretics (dehydration and biochemical abnormalities), antihypertensives (postural hypotension).
• Emotional problems—depression, anxiety, fear, apathy.
• Biochemical abnormalities—hypercalcaemia, DM, electrolyte disturbance, uraemia, liver disease, thyroid dysfunction.
• Poor nutrition
• Prolonged bed rest
• Raised intracranial pressure (drowsiness only).
Treat reversible causes. Provide advice on modification of lifestyle. If drowsiness and fatigue persist, consider a trial of dexamethasone 4–6mg/d or antidepressant. Although steroids make muscle wasting worse, they may improve general fatigue and mobility. Provide psychological support to patients and carers. Consider referral to physiotherapist, review of aids and appliances, review of home layout (possibly with referral to OT), and/or review of home care arrangements.
Occurs with 10% of tumours, particularly myeloma (>30%) and breast cancer (40%).
Presentation and differential diagnosis
Always suspect hypercalcaemia if someone is iller than expected for no obvious reason. Untreated hypercalcaemia can be fatal.
Depending on the general state of the patient, make a decision whether or not to treat the hypercalcaemia. If a decision is made not to treat, provide symptom control and do not check the serum calcium again. If you decide to treat:
• Asymptomatic patient with corrected calcium <3 mmol/L Monitor
• Symptomatic and/or corrected calcium > 3mmol/L Arrange treatment with IV fluids and bisphosphonates via oncologist/palliative care team immediately. Check serum calcium 7–10d post-treatment. 20% do not respond and there is no benefit from re-treating them. Effect of bisphosphonate lasts 20–30d. Consider maintenance with oral bisphosphonates started 1wk after the initial IV treatment or regular IV bisphosphonate. Many who are initially responsive to bisphosphonates become unresponsive with time.
Anorexia, nausea and vomiting
Treat nausea, mouth problems, pain, and other symptoms. ↓ psychological distress and treat depression. Advise small appetizing meals frequently in comfortable surroundings.
General principles of management of nausea and vomiting
• Assess Try to identify likely cause (Table 28.8).
• Review medication Could medication be the cause? Which antiemetics have been used before and how effective were they?
• Try non-drug measures
• Choose an antiemetic If cause can be identified, choose an appropriate antiemetic (Table 28.8). Use the antiemetic ladder (Figure 28.2). Administer antiemetics regularly rather than prn and choose an appropriate route of administration.
• Review frequently Is the antiemetic effective? Has the underlying cause of the nausea/vomiting resolved? Avoid changing antiemetic before it has been given an adequate trial at maximum dose.
Table 28.8 Causes of vomiting and choice of antiemetic
Mechanism of vomiting
Drug/toxin–induced or metabolic e.g. hypercalcaemia
Haloperidol 1.5–5mg nocte
Levomepromazine 6.25mg nocte
If persistent nausea due to opioids, consider changing opioid
Granisetron 1mg bd or ondansetron 8mg bd po or 16mg od pr—chemotherapy- or radiotherapy-induced vomiting
Haloperidol 1.5–5mg nocte—radiotherapy-induced vomiting
Dexamethasone 4–8mg daily po/sc—often given as part of a chemotherapy regime
Metoclopramide 20mg qds
↑ intracranial pressure
Cyclizine 50mg bd/tds (or 150mg/d via syringe driver)
Anxiety, fear, or pain
Benzodiazepines, e.g. diazepam 2–10mg/d or midazolam SC
Cyclizine 50mg bd/tds
Cyclizine 50mg tds po/sc/IM
Hyoscine po (300 micrograms tds) or transdermal (1mg/72h)
Prochlorperazine po (5mg qds) or buccal (3–6mg bd)
Gastric stasis *
Domperidone 10mg tds or metoclopramide 10mg tds (particularly if multifactorial with gastric stasis and a central component)
Stop the irritant if possible, e.g. stop NSAIDs
Proton pump inhibitors, e.g. lansoprazole 30mg od or omeprazole 20mg od
Misoprostol 200 micrograms bd—if caused by NSAIDS
Refer for surgery if appropriate
Cyclizine, haloperidol, or levomepromazine
Dexamethasone 4–8 mg/d—antiemetic and ↓ obstruction.
If vomiting cannot be controlled consider referral for venting gastrostomy or antisecretory agents (e.g. octreotide)
Cyclizine 50mg tds or 150mg/d via syringe driver
Dexamethasone 4–8mg daily po/sc
Metoclopramide 10mg tds/qds po
* Vomits of undigested food without nausea soon after eating.
If there is >1 cause for nausea/vomiting you may need >1 drug.
Route of administration
• For prophylaxis of nausea and vomiting—use po medication
• For established nausea or vomiting—consider a parenteral route e.g. syringe driver ( p.[link])—persistent nausea may ↓ gastric emptying and drug absorption. Once symptoms are controlled consider reverting to a po route.
Do not forget non-drug measures to ↓ nausea.
• Avoidance of food smells and unpleasant odours.
• Relaxation/diversion/anxiety management.
Drugs with antimuscarinic effects (e.g.cyclizine) antagonize prokinetic drugs (e.g. metoclopramide)—if possible, do not use concurrently.
Other GI problems
Review medication making the mouth sore or dry. Refer to the DN for advice on mouth care (e.g. use a toothbrush to keep the tongue clean). Treat oral thrush—fluconazole 50mg od for 7d and soak dentures in Milton fluid for ≥ 12h to prevent reinfection. Consider mouthwashes, e.g. saline, Oraldene®, chlorhexidine gluconate, benzydamine (for pain). Try ¼–½ ascorbic acid 1g effervescent tablet/d— place on tongue and allow to dissolve.
• Painful mouth—benzydamine mouthwash ± lidocaine 10% spray.
• Ulcers or painful areas—triamcinolone in dental paste, or hydrocortisone pellets qds after eating and nocte
• Oral cancer pain—topical NSAIDs, e.g. piroxicam melt
• Chemotherapy-induced ulcers—sucralfate suspension
• Dry mouth—review medication that might be causing dry mouth, e.g. antidepressants, opioids. Try salivary stimulants, e.g. iced water, pineapple chunks, chewing gum, boiled sweets, or mints. Consider saliva substitutes, e.g. Glandosane spray®
• Radiotherapy-induced dryness—pilocarpine
• Excessive salivation—amitriptyline 10–100mg nocte, hyoscine or glycopyrronium via syringe driver.
May be due to physical obstruction (by tumour bulk) or functional obstruction (neurological deficit).
• Treat the cause if possible, e.g. celestin tube for oesophageal tumour
• If the patient is hungry and wishes to be fed, consider referral for a percutaneous endoscopic gastrostomy (PEG)
• If the patient does not wish to have a PEG ask whether he/she would like subcutaneous fluids and treat symptomatically with mouth care, anxiolytics, analgesia, and sedation.
A distressing symptom. Treatment is often unsatisfactory.
• General measures Rebreathing with a paper bag; pharyngeal stimulation by drinking cold water or taking a teaspoonful of granulated sugar.
• Peripheral hiccups Irritation of the phrenic nerve or diaphragm—try metoclopramide (10mg tds), antacids containing simeticone, dexamethasone (4–12mg/d) or ranitidine (150mg bd).
• Central hiccups Due to medullary stimulation, e.g. ↑ICP, uraemia—try chlorpromazine (10–25mg tds/qds), dexamethasone (4–12mg/d), nifedipine (10mg tds), or baclofen (5mg bd).
Free fluid in the peritoneal cavity. Common with ovarian cancer (50% patients). Presents with abdominal distention. Signs: shifting dullness to percussion ± fluid thrill. Depending on clinical state, consider referring for radio- or chemotherapy if appropriate.
• Give analgesia for discomfort.
• Refer for paracentesis and/or peritoneo-venous shunt.
• Try diuretics—furosemide 20–40mg od and/or spironolactone 100–400mg od. May take a week to produce maximal effect. Monitor albumin level—if low, diuretics make ascites worse.
• Dexamethasone 2–4mg daily may help. Discontinue if not effective.
• ‘Squashed stomach syndrome’—try prokinetics, e.g. domperidone or metoclopramide 10mg tds.
Passage of hard stools less frequently than the patient’s own normal pattern. It is a very common symptom. Occult presentations are common in the very elderly and frail and include:
• Urinary retention
• Abdominal pain
• Overflow diarrhoea
• Loss of appetite
Constipation can herald spinal cord compression ( p.[link]). If suspected do a full neurological examination.
Pre-empt constipation by putting everyone at risk (e.g. patients on opioids) on regular aperients. Treat reversible causes, e.g. give analgesia if pain on defecation, alter diet, ↑ fluid intake.
• Treat with regular stool softener (e.g. lactulose) ± regular bowel stimulant (e.g. senna) or a combination drug (e.g. co-danthrusate). Titrate dose against reponse.
• If that is ineffective, consider adding rectal measures. If soft stools and lax rectum, try bisacodyl suppositories ( must come into direct contact with rectum). If hard stools, try glycerol suppositories—insert into the faeces and allow to dissolve.
• If still not cleared, refer to the district nurse for lubricant ± stimulant enema (usually acts in ~20 min). Once cleared, leave on a regular aperient with instructions to ↑ aperients if constipation recurs.
Connections from the gut to other organs—commonly skin, bladder or vagina. Bowel fistulae are characterized by air passing through the fistula channel. If well enough for surgery, refer to a surgeon. If not fit for surgery, consider referring to palliative care for octreotide.
Clarify what the patient/carer means by diarrhoea. Less common than constipation but can be distressing for the patient and difficult for the carer, especially if incontinence results.
• ↑ fluid intake—small amounts of clear fluids frequently.
• Screen for infection (including pseudomembranous colitis if diarrhoea after a course of antibiotics) and treat if necessary.
• Ensure no overflow diarrhoea 2° to constipation, no excessive/erratic laxative use, and no other medication is causing diarrhoea.
• Consider giving aspirin (300–600mg tds)—↓ intestinal electrolyte and water secretion caused by prostaglandins. May particularly help with radiotherapy-induced diarrhoea.
• Consider ondansetron 4mg tds for radiotherapy-induced diarrhoea.
• Consider giving pancreatic enzyme supplements, e.g. Creon® 25000 tds prior to meals if fat malabsorption (e.g. 2° to pancreatic carcinoma).
• Otherwise treat symptomatically with codeine phosphate 30–60mg qds or loperamide 2mg tds/qds.
• Refer to palliative care if unable to control symptoms.
Skin, neurological, and orthopaedic problems
Due to pressure necrosis of the skin. Immobile patients are at high risk, especially if frail ± incontinent. Likely sites of pressure damage—shoulder blades, elbows, spine, buttocks, knees, ankles, and heels. Bed sores heal slowly in terminally ill patients and are a source of discomfort and stress for both patients and carers (who often feel guilty that a pressure sore is a mark of poor care).
• If at risk refer to the DN for palliative care nursing team for advice on prevention of bed sores—protective mattresses and cushions, incontinence advice, advice on positioning and movement.
• Warn carers to make contact with the DN or palliative care nursing team if a red patch does not improve 24h after relieving the pressure on the area.
• Treat any sores that develop aggressively and admit if not resolving.
Large wounds can have a major impact on quality of life. Patients with advanced disease have major risk factors for development and poor healing of wounds—immobility, poor nutrition, skin infiltration ± breakdown due to malignancy. Skin infiltration causing ulceration or fungating wounds can be particularly distressing.
The primary aim is comfort. Healing is a secondary aim and may be impossible. Always involve the DN and/or specialist palliative care nursing team early. Many hospitals also have wound care specialist nurses who are invaluable sources of advice.
Specific management problems
Table 28.9 Common wound management problems
Exclude infection; ensure the dressing is comfortable; limit frequency of dressing changes
Ensure adequate background analgesia; consider additional analgesia for dressing changes and/or topical opioids on the dressing
Use high-absorbency dressings with further packing on top ± plastic pads to protect clothing
Change the top layer of the dressing as often as needed but avoid frequent changes of the dressing placed directly on the wound
Protect the surrounding skin with a barrier cream/spray
Use desloughing agents
Referral for surgical debridement may be necessary
Prevent bleeding during dressing changes by:
If there is surface bleeding, put pressure on the wound; if pressure is not working try:
Consider referral for radiotherapy or palliative surgery (e.g. cautery)
Treat with systemic and/or topical metronidazole
Charcoal dressings can be helpful
Seal the wound, e.g. with additional layer of clingfilm dressing
Try disguising the smell with deodorisers (e.g. Nilodor®) used sparingly on top of the dressing—short-term measure. Long term the deodorant smell often becomes associated with the smell of the wound for the patient
Usually chronic and localized
Irrigate the wound with warm saline or under running water in the shower/bath
If the surrounding skin is inflamed, swab the wound and send for M,C&S. Then start oral antibiotics, e.g. flucloxacillin 250–500mg qds or erythromycin 250–500mg qds. Alter antibiotics depending on sensitivities of the organisms grown
Raised intracranial pressure
Occurs with 1° or 2° brain tumours. Characterized by
• Headache—worse on lying
• Unless a terminal event, refer urgently to neurosurgery for assessment. Options include insertion of a shunt or cranial radiotherapy.
• If no further active treatment is appropriate, start symptomatic treatment—raise the head of the bed, start dexamethasone 16mg/d (stop if no response in 1wk), analgesia.
Spinal cord compression
Common in advanced cancer due to osteoporosis, trauma as a result of falls, or metastases. Have a low index of suspicion if a new bony pain develops. Treat with analgesia. Unless in a very terminal state, confirm the fracture on X-ray and refer to orthopaedics or radiotherapy urgently for consideration of fixation (long bones, wrist, neck of femur) and/or radiotherapy (rib fractures, vertebral fractures).
In the elderly, fracture of a long bone can present as acute confusion.
Troublesome symptom. Prolonged bouts of coughing are exhausting and frightening, especially if associated with beathlessness and/or haemoptysis.
Affects 70% of terminally ill patients. It is usually multifactorial. Breathlessness always has a psychological element—being short of breath is frightening. Causes—Figure 28.3.
Management of cough and breathlessness
General non-drug measures
• Reassure. Explain reasons for breathlessness/cough and adaptations to lifestyle which might help, e.g. sitting up straight.
• Breathing exercises can help—refer to physiotherapy.
• Steam inhalations or nebulized saline can help with tenacious secretions.
• Try a stream of air over the face if the patient is breathless, e.g. fan, open window
General drug measures
• Try simple linctus 5–10mL prn for cough.
• Oral or subcutaneous opioids ↓ subjective sensation of breathlessness—start with 2.5mg morphine sulphate solution every 4h and titrate upwards. Opioids may also help with cough—try pholcodine 10mL tds or morphine sulphate solution as for breathlessness. If already on opioids, ↑ dose by 25%. Titrate dose until symptoms are controlled or side effects.
• Try benzodiazepines—2–5mg diazepam od/bd for background control of breathlessness + lorazepam 1–2mg s/ling prn in between. Diazepam acts as a central cough suppressant—try 2–10mg tds for cough.
• Oxygen has a variable effect and is worth a try
• Hyoscine hydrobromide 400–600 micrograms every 4-8h (or 0.6–2.4mg/24h via syringe driver) and/or ipratropium inhalers/nebulized ipratropium ↓ secretions.
• Chest infection Treat with nebulized saline to make secretions less viscous ± antibiotics (if not considered a terminal event).
• Post-nasal drip Steam inhalations, steroid nasal spray or drops ± antibiotics.
• Laryngeal irritation Try inhaled steroids, e.g. beclometasone 100 micrograms/actuation 2 puffs bd
• Bronchospasm Try bronchodilators ± inhaled or oral steroids. Salbutamol may help cough even in the absence of wheeze.
• Gastric reflux Try antacids containing simeticone
• Lung cancer Try inhaled sodium cromoglicate 10mg qds; local anaesthesia using nebulized bupivacaine or lidocaine can be helpful— refer for specialist advice (avoid eating/drinking for 1h afterwards to avoid aspiration). Palliative radiotherapy or chemotherapy can also relieve cough in patients with lung cancer—refer.
Coarse wheezing sound which results from obstruction of a major airway, e.g. larynx.
Haematological and vascular problems
In all patients likely to bleed (e.g. in end-stage leukaemia) pre-warn carers and give them a strategy.
Severe life-threatening bleed
Decide whether the cause of the bleed is treatable or a terminal event. This is best done in advance, but bleeding cannot always be predicted.
• Severe bleed—active treatment p.[link]
• Severe bleed—no active treatment
• Stay with the patient.
• Give sedative medication, e.g. midazolam 20–40mg sc/IV or diazepam 10–20mg PR and diamorphine 5–10mg sc/IV.
• Support carers as big bleeds are extremely distressing.
First aid measures
• In all cases: reassure; monitor frequently.
• Surface bleeding—pressure on wound; if pressure is not working try Kaltostat® or adrenaline (1mg/mL or 1:1000) on a gauze pad.
• Nose bleeds—nasal packing or cautery.
Follow-up is directed at cause if appropriate.
• Anticoagulants—check INR.
• Treat infection that might exacerbate a bleed.
• Consider ↓ bleeding tendency with tranexamic acid 500mg qds.
• Upper GI bleeding—stop NSAIDs, start PPI at double standard dose, and consider referral for gastroscopy.
• Lower GI bleeding—consider rectal steroids to ↓ inflammation or rectal tranexamic acid ± referral for colonoscopy.
• Radiotherapy—consider referral if haemoptysis, cutaneous bleeding, or haematuria.
• Referral for chemotherapy or palliative surgery (e.g. cautery) are also options
Do not check for anaemia if no intention to transfuse.
• If Hb <10g/dL and symptomatic Treat any reversible cause (e.g. iron deficiency, GI bleeding 2° to NSAIDs). Consider transfusion.
• If transfused Record whether any benefit is derived (as if not, further transfusions are futile) and the duration of benefit (if <3wk—repeat transfusions are impractical). Monitor for return of symptoms; repeat FBC and arrange repeat transfusion as needed.
Superior vena cava (SVC) obstruction
Due to infiltration of the vessel wall, clot within the superior vena cava, or extrinsic pressure. 75% are due to 1° lung cancer (3% of patients with lung cancer have SVC obstruction). Lymphoma is the other major cause.
• Shortness of breath/stridor.
• Headache worse on stooping ± visual disturbances ± dizziness and collapse.
• Swelling of the face, particularly around the eyes, neck, hands, and arms, and/or injected cornea.
• Examination: look for non-pulsatile distention of neck veins and dilated collateral veins (seen as small dilated veins over the anterior chest wall below the clavicles) in which blood courses downwards.
• Treat breathlessness (opioids—5mg morphine sulphate solution every 4h ± benzodiazepine depending on the level of anxiety).
• Start corticosteroid (dexamethasone 16mg/d.).
• Refer urgently for oncology opinion. Palliative radiotherapy has a response rate of 70%. Stenting ± thrombolysis is also an option.
Due to obstruction of lymphatic drainage resulting in oedema with high protein content. Affects ≥1 limbs ± adjacent trunk. If left untreated, lymphoedema becomes increasingly resistant to treatment due to chronic inflammation and subcutaneous fibrosis. Cellulitis causes rapid ↑ in swelling. Causes:
• Axillary, groin or intrapelvic tumour
• Extensive axillary or groin surgery
• Post-operative infection/radiotherapy.
• Swollen limb ± pitting
• Impaired limb mobility and function
• Discomfort/pain related to tissue swelling and/or shoulder strain
• Neuralgic pain, especially when axillary nodes are involved
• Psychological distress.
Table 28.10 Management of lymphoedema
Avoid injury to limb
In at-risk patients (e.g. patients who have had breast cancer with axillary clearance) or those with lymphoedema, injury to the limb may precipitate or worsen lymphoedema. Do not take blood from the limb or use it for IV access or vaccination
Skin care with moisturizers, e.g. aqueous cream, Emulsiderm.
Topical treatment of fungal infection
Systemic treatment of bacterial infection
Intensive—with compression bandages
Maintenance—with lymphoedema sleeve (contact breast care specialist nurse for more information on obtaining sleeves)
Gentle daily exercise of affected limb, gradually increasing range of movement
Must wear a sleeve/bandages when doing exercises
Very gentle fingertip massage in the line of drainage of lymphatics
If the condition has developed or deteriorated since prescription of corticosteroid or NSAID or if there venous component, consider trial of diuretics
Otherwise diuretics are of no benefit
All patients with terminal disease are anxious at times for a variety of reasons, including fear of uncontrolled symptoms and of being left alone to die. When anxiety starts interfering with quality of life, intervention is justified.
—often all that is needed:
• Acknowledgement of the patient’s anxiety.
• Full explanation of questions + written information as needed.
• Support—self-help groups, day care, patients’ groups, specialist home nurses (e.g. Macmillan Nurses).
• Relaxation training and training in breathing control.
• Physical therapies, e.g. aromatherapy, art therapy, exercise.
• Acute anxiety Try lorazepam 1–2mg SL prn or diazepam 2–10mg prn
• Chronic anxiety Try an antidepressant, e.g. sertraline 50mg od. Alternatives include regular diazepam, e.g. 5–10 mg od/bd, haloperidol 1–3mg bd/tds, or ²-blockers, e.g. propranolol 40mg od/tds—watch for postural hypotension.
If anxiety is not responding to simple measures, seek specialist help from either the psychiatric or palliative care team.
A terminal diagnosis commonly makes patients sad. 10–20% of terminally ill patients develop clinical depression but, in practice, it is often difficult to decide whether a patient is depressed or just appropriately sad about his/her diagnosis and its implications. Many symptoms of terminal disease (e.g. poor appetite) are also symptoms of depression, so depression screening questionnaires are often unhelpful. If in doubt, a trial of antidepressants can help.
Assessment of suicide risk
Ask about suicidal ideas and plans in a sensitive but probing way. It is a common misconception that asking about suicide can plant the idea into a patient’s head and make suicide more likely. Evidence is to the contrary.
• Support, e.g. day and/or respite care; carers’ group; specialist nurse support (e.g. Macmillan Nurse, CPN); ↑ help in the home.
• Relaxation often ↑ the patient’s feeling of control over the situation.
• Explanation of worries/problems/concerns about the future.
• Physical activity—exercise; writing.
• Consider starting an antidepressant— p.[link]
• All antidepressants take ~2wk to work.
• If immediate effect is required, consider using flupentixol 1mg od (beware as can cause psychomotor agitation).
If not responding or suicidal refer for psychiatric opinion.
Terminal anguish and spiritual distress
Characterized by overwhelming distress. Often related to unresolved conflict, guilt, fears, or loss of control.
Anxiety can be increased if
• Patients are unaware of the diagnosis, but feel people are lying to them.
• They are experiencing breathlessness, haemorrhage, or constant nausea or diarrhoea.
• Weak religious conviction—convinced believers and convinced non-believers have less anxiety.
• There are young dependent children or other dependent relatives.
• Patients have unfinished business to attend to, such as legal affairs.
The last 48 hours
It is notoriously difficult to predict when death will occur. Symptoms and signs of approaching death include:
• Day-by-day deterioration
• Gaunt appearance
• Difficulty swallowing medicines
• ↓ intake of food and fluids
• Profound weakness—needs assistance with all care, may be bedbound.
• Drowsy or ↓ cognition—often unable to cooperate with carers.
Goals of treatment in the last 48 hours
• Ensure patients are comfortable—physically, emotionally, and spiritually
• Make the end of life peaceful and dignified. What is dignified for one patient may not be for another—ask.
• Support patients and carers so that the experience of death for those left behind is as positive as possible.
Dying is a unique and special event for each individual. Helping to explore a patient’s wishes about death and dying should not be a discussion left to the last 24h.
Advance directives/living wills/lasting power of attorney
Out of hours providers
Alert out of hours providers if a patient is dying at home. This will ensure appropriate response to calls, and avoid unnecessary and unwanted admissions. Consider a ‘just-in-case’ box to leave at the patient’s home containing drugs that might be needed should the patient deteriorate outside normal working hours.
Different religious and cultural groups have different approaches to the dying process. Be sensitive to cultural and religious beliefs. If in doubt, ask a family member.
Assessment of patient needs
Ask which problems are causing the patient/carers most concern, and address those concerns where possible. Patients often under-report symptoms.
Keep examination to a minimum to avoid unnecessary interference. Check sites of discomfort/pain suggested by history or non-verbal cues: mouth, bladder, and bowel.
Find out what the patient wants to know. Gently assessing how the patient feels about their disease and situation can shed light on their needs and distress.
Dying patients tolerate symptoms very poorly because of their weakness. Nursing care is the mainstay of treatment. However, GPs do have a role:
• Ensure that new problems do not develop, e.g. use of appropriate mattresses and measures to prevent bed sores.
• Treat specific symptoms, e.g. dry mouth.
• Think ahead—discuss treatment options that might be available later, e.g. use of a syringe driver, buccal, PR or transcutaneous preparations to deliver medication when/if the oral route is no longer possible, use of strong analgesia which may also have a sedative effect.
• Ensure that a clear management plan is agreed between the medical and nursing team and the patient/family members. Anticipate probable needs of the patient so that immediate response can be made when the time comes: define clearly what should be done in the event of a symptom arising/worsening; ensure drugs or equipment that may be needed are in the home; inform the out-of-hours service.
Excessive respiratory secretion (death rattle)
Noisy moist breathing. Can be distressing for relatives. Reassure that the patient is not suffering or choking. Try repositioning and/or tipping the bed head down (if possible) to ↓ noise. Treat prophylactically—it is easier to prevent than remove accumulated secretions. Suitable drugs:
• Glycopyrronium—non-sedative. Give 200 micrograms sc stat and review after 1h. If effective, give 200 micrograms sc every 4h or 0.6–1.2mg/24h via syringe driver.
• Hyoscine hydrobromide—sedative in high doses. give 400 micrograms sc stat and review response after 30min. If effective, give 400–600 micrograms every 4–8h or 0.6–2.4mg/24h via syringe driver. If patient is conscious and respiratory secretions are not too distressing, it may be more appropriate to use a transdermal patch (Scopaderm® 1.5mg over 3d) or sublingual tablets (Kwells®). Dry mouth is a side effect.
Distressing symptom for patients/carers. Support carers in attendance and explain management:
• Diamorphine or morphine: dose depends on whether the patient is being converted from oral morphine (or an alternative opioid), to diamorphine. If no previous opioid, start diamorphine 5mg/24h sc. If previously on oral morphine, divide the total 24 h dose by 3 to obtain the 24h s/cut dose. ↑ dose slowly as needed.
• Midazolam 5–10mg/24h sc.
• If sticky secretions—try nebulised saline ± physiotherapy.
• Pain/discomfort Urinary retention, constipation, pain which the patient cannot tell you about, excess secretions in throat.
• Opioid toxicity Causes myoclonic jerking. The dose of morphine may need to be ↓ if a patient becomes uraemic.
• Biochemical causes ↑ Ca2+, uraemia. if it has been decided not to treat abnormalities, do not check for them.
• Psychological/spiritual distress.
Treat reversible causes, e.g. catheterization for retention, hyoscine to dry up secretions. If still restless, treat with a sedative. This does not shorten life but makes the patient/relatives more comfortable. Suitable drugs: haloperidol 1–3mg tds po; chlorpromazine 25–50mg tds po; diazepam 2–10mg tds po, midazolam (10–100mg/24h via syringe driver or 5mg stat) or levomepromazine (50–150mg/24h via syringe driver or 6.25mg stat).
Terminal anguish and spiritual distress