Key notes on symptom control issues in Palliative Care

Prognosis

If the patient has two or more episodes of hypercalcaemia or has metastatic breast cancer consider either:

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  Regular monthly or bimonthly pamidronate infusions using 90mg dose
  
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  Regular oral bisphosphonates, although compliance due to side effects may be an issue.
  

Management of the last days of life

This is a difficult time for all concerned. Professional carers may need a way of being able to acknowledge and share their feelings. The mutual support of working in a multi-professional team can be very important.
It may be hard to recognise when death is imminent but it is usually heralded by a more rapid deterioration in the patient’s general condition and the following:

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  Profound weakness with the patient bed-bound and drowsy for long periods.
  
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  Disorientated in time
  
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  Limited attention span of a few minutes
  
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  Disinterested in food and drink and the world around them
  
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  Too weak to swallow medication
  

If the approach of death is recognised, this allows the withdrawal of unnecessary treatments such as anti-hypertensives, appetite stimulants etc.. It also allows the family and in some instances the patient to prepare for death. It can be difficult to ask directly about the patient and family’s perceptions of how close death is, but if it is possible to do so, it allows for the most appropriate management plan to be negotiated. This will include looking at the preferred place of death and whether this is achievable with the resources (both professional and informal) available. The wishes of the patient may already be known to the primary care team and the family, but they should be checked out again as death approaches. Many patients and carers have unfinished business. This may be legal (drawing up a will), financial, interpersonal or spiritual. Be prepared to ask broad questions and help the family and patient to access the appropriate help from the appropriate ‘expert’.