Key notes on symptom control issues in Palliative Care

CONTENTS

PAGE

Introduction 2
Pain 3 - 4

Visceral 3 - 4

Bone 4

Neuropathic 4
Nausea & Vomiting 5 - 7

Chemical or drug induced 5

Impaired intestinal motility 5

Raised intracranial pressure 6

Movement related 6

Regurgitation 6

Anxiety 6
Intestinal obstruction 7
Respiratory Symptoms 8 – 11

Breathlessness 8

Cough 9

Haemoptysis 10

Respiratory tract secretions 11
Spinal Cord compression 12
Superior Vena Caval Obstruction (SVCO) 13
Hypercalcaemia 14 – 15
Management of the last days of life including terminal restlessness 16 – 17
Miscellaneous symptoms 18 - 22

Liver capsular pain 18

Squashed stomach syndrome 18

Hiccups 19

Sweating 20

Itch 20

Anorexia 21

Dry mouth 22

Fatigue 22
Use of steroids in palliative care 23
Indications for the use of a syringe driver 24
Key notes on symptom control issues in Palliative Care
Most palliative care is straightforward, relying on common sense and good general medical and nursing care. Good palliative care is as much about good communication skills, empathy and wisdom as it is about medical and nursing knowledge. For most patients who choose to remain at home, it is carried out best by the people who know the patient and family well, in the place the patient feels most comfortable, i.e. at home with their family and friends, being cared for by their primary care team.
The following pages contain some general guidance about some of the commoner symptoms experienced by people suffering from cancer. The guidance focuses on those areas where practice differs from other fields of medicine, but it is not exhaustive. It is written as a guide on how to start to manage those symptoms that may not be encountered very frequently in general practice and to indicate when to seek specialist advice and support. The guidance is not intended to replace the local specialist advice each primary care team has available to them.
It is good practice to ask the question ‘why’ when any patient with a life threatening illness develops new symptoms or appears to deteriorate rapidly. As with all areas of medicine there are certain symptoms that should ring alarm bells and which demand a rapid response, not only from the primary care team but also the specialists. If there is no straightforward explanation for a patient’s deterioration, or the patient has had radical radiotherapy or any form of chemotherapy, consider referral back to their oncology unit or centre. At the very least such patients should be discussed with the specialist services to ensure treatment related conditions such as neutropenic sepsis have been excluded.
As a specialist in Palliative Medicine I was asked to write these guidance notes for our local primary care teams. It was hoped they would contribute to the ongoing education of staff on palliative care issues and to support them in the excellent work they do in managing complex and challenging patients at home:
Dr Susan Salt

Macmillan Consultant in Palliative Care

Calderdale & Huddersfield NHS Trust

Calderdale Royal Hospital

Salterhebble

Halifax HX3 0PW

I offer my sincere thanks to Dr Mary Kiely, Consultant in Palliative Medicine, Huddersfield Royal Infirmary and Dr Liz Higgins, Consultant in Palliative Medicine, Kirkwood Hospice, Huddersfield who have reviewed and them.

Pain

Pain is what the patient says it is. Approximately 25% of all cancer patients will have pain at diagnosis. Up to 75% of all cancer patients will have pain in advanced disease. There are three main types of pain. These may co-exist and therefore it may be necessary to use more than one approach to achieve adequate pain control. The three different types are:

• 
  Visceral – tumour bulk, bowel obstruction
  
• 
  Bony – replacement of bone by tumour, pathological fracture
  
• 
  Neuropathic – nerve injury or nerve compression
  

Always take a careful history and carry out an appropriate examination. Identify the likely pathological process(es) contributing to the pain, and where possible treat reversible causes such as infection or fracture. Analgesia should not wait for investigations to be completed. The pain associated with cancer and other life limiting illnesses is usually chronic and needs regular medication to keep it under control. Adequate doses of analgesia on an ‘as required basis’ in addition to the regular medication must be made available. Where possible give analgesia by mouth, by the clock and by the ladder (see flow diagram). Pain that does not respond to oral medication is unlikely to respond to parental medication unless there are absorption problems.

• 
  Review the effectiveness of any intervention on a regular basis.
  
• 
  Ensure all patients on a step 2 or step 3 analgesic are on regular laxatives and that the effectiveness of the laxative regimen is being adequately monitored.
  
• 
  Remember the role of rest, relaxation, adequate sleep, explanation, heat pads, TENs machine and massage in aiding pain control and encourage the patient to use self-help measures.
  

Visceral pain

Visceral pain
Step one	Take a thorough history	Diagnose the cause and treat if possible
Step two	Follow the WHO ladder	Add in regular paracetamol
Step three	Add in an adjuvant analgesic	Ask for help

• 
  Paracetamol. May be particularly effective for some types of headaches and musculoskeletal pain. In combination with codeine (30mg) it is the step 2 analgesic of choice. Always prescribe a laxative if codeine is being used.
  
•