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Palliative care 

Palliative care
Chapter:
Palliative care
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0059
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date: 29 November 2021

General points

Palliative care is defined by the World Health Organization (WHO) as an approach that improves the QoL of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, impeccable assessment, and treatment of pain and other problems, physical, psychosocial, and spiritual. Palliative care is moving away from being involved just at the end of life, especially in developing countries when curative possibilities are less readily available and palliative treatments may be the only option. In the UK, patients may be under palliative care teams intermittently for symptom control, respite care, etc. and may not see the service again for months or years.

Within chest medicine, palliative care is most commonly considered for patients with lung cancer and mesothelioma; many other patients with progressive end-stage respiratory disease (such as COPD, CF, and fibrotic lung disease) also benefit from specific palliative interventions. These two areas are discussed separately in this chapter, although there is much overlap in the management.

Lung cancer and mesothelioma

  • Involve the specialist palliative care team early

  • Treat symptoms promptly

  • An open discussion of patients’ fears is often helpful, as is a calm and explicit logical approach to symptom management

  • Recognize problems are often mixed, complex, and multiple

  • Recognize that delirium, dyspnoea, and decreased mobility often herald the terminal phase of cancer.

Pain

  • Aim to determine cause, type, and site

  • Start with simple analgesia, and increase according to the WHO analgesic ladder, moving from non-opioid analgesia (paracetamol, NSAIDs) through weak opioids (codeine, tramadol) to strong opioids (morphine, diamorphine, fentanyl, etc.), while also considering adjuvant therapy (e.g. antidepressants, antiepileptics). Reassess repeatedly and regularly

  • If moving to morphine from a weak opioid, 40–60mg morphine daily should be adequate (given either 4-hourly immediate release or 12-hourly modified-release preparations). 60mg codeine qds is equivalent to 24mg total daily morphine. If the first dose of morphine is no more effective than previous analgesia, increase next dose by 50%

  • Prescribe analgesia as required for breakthrough pain (see Box 59.1)

  • Give drugs a chance to work at appropriate doses, particularly if they have not had strong opioids before. Allows assessment of analgesic effect and side effects. Usually increase every 3rd day if required

  • Once pain is reasonably controlled, morphine dose can be converted to slow-release morphine by dividing total daily amount by two and giving that dose as modified-release morphine 12-hourly (see Box 59.2). The additional breakthrough dose is 1/6 of the total 24h dose (e.g. if using 15mg modified-release morphine bd, then use an additional 5mg immediate-release morphine sulfate for breakthrough pain)

  • Treat drug side effects, e.g. constipation, nausea. Prescribe prophylactic laxatives with morphine. Warn people they may feel more drowsy if starting morphine or having dose increase, but this usually settles within a few days

  • Patients with renal failure are more likely to develop opioid toxicity (drowsiness, confusion, myoclonus), as they have difficulty excreting morphine metabolites. They may need alternatives to morphine (e.g. oxycodone, methadone, alfentanil, fentanyl) if their pain is not controlled on low-dose morphine

  • The addition of an anti-inflammatory drug or steroids can be effective for bone pain and for liver capsule pain if there are hepatic metastases

  • Consider radiotherapy for localized pain in the chest related to cancer

  • Pleuritic pain Consider PE; treat any infection. Consider NSAID ± intercostal nerve block

  • Bone metastases causing local tenderness Start a strong opioid. If there is no improvement after three dose increases, add an NSAID for a 1-week trial. If single site, consider radiotherapy or intercostal nerve block. If multiple sites, consider bisphosphonates (provided not hypocalcaemic), e.g. 90mg of pamidronate IV every 4 weeks

  • Neuropathic pain can be treated with tricyclic antidepressants (e.g. amitriptyline started at 10–25mg nocte or nortriptyline) or antiepileptics (e.g. pregabalin started at 75mg bd or gabapentin). In some cases, there may be a role for lidocaine patches or capsaicin cream

  • Pain from chest drain tract metastases Use analgesia, and refer for radiotherapy

  • Consider referral to pain clinic or specialist centre for further intervention such as a intercostal nerve block, transcutaneous electrical nerve stimulation (TENS), cervical cordotomy, or complementary therapies.

Dyspnoea

  • Consider possible causes (see Box 59.3). Dyspnoea may be due to the underlying lung disease or due to an additional pathology

  • Dyspnoea is frightening and made worse by anxiety and panic. Explain to patient that alleviation of dyspnoea is possible for most patients with appropriate treatment

  • Lung cancer and pulmonary metastases are associated with the sensation of SOB, often due to stimulation of receptors by malignant infiltration or lymphangitis carcinomatosis

  • Optimize treatment of any underlying lung disease with bronchodilators and steroids, if appropriate

  • Treat concurrent chest infection

  • Give advice on planning and adapting daily activities to conserve energy

  • Fan blowing cool air onto the face/open window can be helpful

  • Consider patient positioning when in bed—upright posture assists diaphragmatic excursion; lying tilted may help with copious secretions

  • Opioids (e.g. 2.5–5mg morphine sulfate solution 4-hourly) relieve the sensation of dyspnoea without affecting respiratory function

  • O2 cylinders/concentrator for intermittent short-burst/prn use may help symptoms but may be associated with psychological dependence, may restrict daily activities, and may dry the upper airways

  • Consider the need for external beam radiotherapy, endobronchial tumour debulking, or airway stenting in a patient with lung cancer experiencing dyspnoea due to bronchial obstruction or compression with tumour

  • If PE diagnosed, consider treatment with LMWH, instead of warfarin (avoids need for repeated blood tests and has a potential anti-mitotic effect)

  • SC opioid infusion may relieve symptoms as death approaches; use with haloperidol, midazolam, or levomepromazine.

Other symptoms

Anxiety

  • Leads to dyspnoea, which, in turn, worsens anxiety

  • Reassure patients they will not suffocate; symptoms will pass

  • Benzodiazepines (such as short-acting lorazepam 0.5–1mg sublingually 8–12-hourly) are effective for respiratory panic. Longer-acting diazepam 2–5mg nocte/bd may be helpful for severe anxiety or at night when dyspnoea and panic disturb sleep

  • Acute panic may be helped by midazolam 2.5mg IV, increased in increments of 1mg, given in a controlled environment with O2

  • Amitriptyline or citalopram may be effective longer-term treatments

  • Cannabinoids, such as nabilone, may be useful for patients who have continuous dyspnoea, anxiety and who do not tolerate other agents

  • Relaxation exercises, diaphragmatic breathing training, and complementary therapies may help some patients.

Cough

  • Treat the underlying cause

  • Try simple or codeine linctus

  • Nebulized saline may help expectoration

  • Codeine 30mg qds (or even morphine sulphate solution) may be of use for intractable cough

  • Methadone linctus 1–2mg nocte or bd may be used but has a long duration of action and may accumulate

  • Nebulized local anaesthetic may help, e.g. 5mL 2% lidocaine 6-hourly or bupivacaine 5ml 0.25% 8-hourly (avoid in asthmatics, as it causes bronchospasm). Pharyngeal numbness is likely to occur, so avoid fluids for 1–2h afterwards

  • Consider radiotherapy if haemoptysis due to lung cancer. Consider discontinuing antiplatelet drugs or anticoagulants

  • If massive haemoptysis, consider tranexamic acid, plus emergency supply of opioids and benzodiazepines to ensure pain control and reduction of fear by decreasing awareness.

Pleural effusion

  • Drain if symptomatic, and pleurodese early if recurrent, although not if prognosis is poor (<3 months)

  • Consider IPC to drain fluid if effusion is symptomatic and talc pleurodesis has failed or with completely trapped lung. RCT evidence suggests also reasonable to use IPC for 1° therapy (in place of talc pleurodesis), but patient choice key (see Palliative care p. [link]).

Poor appetite

  • Common symptom; may be 1°, due to cachexia-anorexia syndrome, or 2° due to mouth problems (such as candidiasis), nausea, hypercalcaemia, drugs, or depression

  • May be improved in the short term (about 6 weeks) by a course of oral steroids such as dexamethasone 4mg bd or prednisolone 20mg daily

  • Cachexia leads to decreased respiratory muscle strength and increased SOB

  • Consider nutritional supplements.

Brain metastases

  • Steroids relieve the cerebral oedema associated with brain metastases, e.g. dexamethasone 8mg bd (8 a.m. and 2 p.m.) initially and then decrease

  • Avoid steroid dosing in the evening, as sleep is affected

  • Palliative whole brain radiotherapy should be considered for patients with performance status 0/1 or if there is a good response to steroids.

Recurrent laryngeal nerve palsy

  • Affects 10% of patients with lung cancer, causes hoarse voice

  • Patients with troublesome hoarseness should be referred to ENT for consideration of Teflon® stiffening of vocal cord to prevent paradoxical movement.

Non-malignant respiratory disease (COPD, CF, fibrotic lung disease)

The main problems associated with severe non-malignant respiratory disease are dyspnoea, hypoxia, immobility, and psychosocial problems, including depression. End-stage COPD patients may have very frequent exacerbations for some years before a final terminal event. One study has shown those with end-stage COPD are more likely to have depression ± anxiety than those with terminal cancer, but they are less likely to receive specific treatment for their emotional problems or any targeted palliative care. It may be appropriate therefore to shift the focus in patients with severe end-stage respiratory disease away from management of acute exacerbations towards a more palliative approach to care.

Dyspnoea

  • Dyspnoea is frightening and made worse by anxiety and panic

  • Patients may decrease their mobility to avoid dyspnoea and subsequently become more deconditioned

  • Dyspnoea may be due to the underlying lung disease or an additional pathology (PE, infection, pneumothorax, cardiac failure)

  • Sitting upright reduces airway obstruction and optimizes ventilation. Relaxing and dropping the shoulders can improve ventilation when anxiety has caused patient to ‘hunch up’

  • Calm gentle reassurance can decrease anxiety and reduce dyspnoea

  • Fan blowing cool air onto the face/open window can be helpful

  • Optimize treatment of any underlying lung disease with bronchodilators and inhaled steroids, if appropriate

  • Treat concurrent exacerbations with antibiotics and oral steroids

  • Stop smoking

  • Consider pulmonary rehabilitation

  • Opioids (e.g. 2.5–5mg morphine sulfate solution prn/4-hourly) relieve the sensation of dyspnoea without affecting respiratory function. Consider pre-emptive use for known triggers of breathlessness

  • O2 cylinders for intermittent short-burst use may help symptoms. Consider concentrator if multiple cylinders being used.

Hypoxia

  • SaO2 <92%

  • LTOT may be appropriate (see Palliative care p. [link])

  • O2 cylinders for intermittent or ambulatory use may help symptoms, but little data to support their use

  • NIV use appropriate for some causes of ventilatory failure (see Palliative care pp. [link][link]).

Anxiety and depression

  • May be due to fear and uncertainty over prognosis

  • Lead to dyspnoea, which, in turn, worsens anxiety

  • Explain they will not suffocate; symptoms will pass

  • Benzodiazepines (such as short-acting lorazepam 0.5–1mg sublingually 8–12-hourly) are effective for respiratory panic

  • Acute panic may be helped by midazolam 2.5mg IV, increased in steps of 1mg, given in a controlled environment with O2

  • Depression rates are high in patients with COPD. Consider antidepressant treatment and counselling. Amitriptyline or citalopram may be effective at helping anxiety also

  • Relaxation exercises, diaphragmatic breathing training, and complementary therapies may help some patients.

Cough

  • Treat the underlying cause

  • Refer to physiotherapy to improve cough efficacy, particularly if large-volume secretions

  • Consider mucolytics, steroids, antibiotics

  • Try simple or codeine linctus

  • Nebulized saline may help expectoration

  • Oral local anaesthetics, such as benzocaine and lidocaine lozenges, may be useful for laryngeal, pharyngeal, or tracheal irritation, but associated risk of aspiration

  • Nebulized local anaesthetic may help, e.g. 5mL 2% lidocaine 6-hourly or bupivacaine 5ml 0.25% 6-hourly (avoid in asthmatics, as it causes bronchospasm). Pharyngeal numbness is likely to occur, so avoid fluids for 1–2h afterwards.

Other problems

  • Malnutrition, thirst

  • Nausea, vomiting, constipation

  • Sleep disturbance

  • Chest pain

  • Fatigue

  • Oral candidiasis

  • Impact on carers and family of patient with chronic respiratory disease.

Further information

British National Formulary—useful information on prescribing in palliative care in its first section.

Liverpool Care Pathway—used by many hospitals to enable health care workers to deliver optimum hospice-type care to a dying patient, whatever their location or diagnosis. Further information at: Palliative care http://www.sii-mcpcil.org.uk/lcp.aspx.