1. “Palliative Care” Dr David Plume MBBS DRCOG MRCGP Macmillan GPF, GP Advisor and Primary Care Network Lead.

2. “Palliative Care” • “talk about medicine” or “talk about air” • Enormous subject! • Feedback regarding questionnaires and PPoC • Choice of Topic Areas: • Symptom Control inc Breathlessness and Nausea/Vomiting, setting up a syringe driver. • Current initiatives/developments inc improved drug charts for EOL, transferable DNACPR forms, end of treatment letters etc. • Q and A

3. Local Feedback-Questionnaires • In late 2007 and again in late 2008 I sent out questionnaires looking at twenty nine criteria for palliative care provision in 1’ care. • These included; • Nominated lead? • Keeping a list? • Information getting to 1’ care rapidly enough? • Support for patients on the cancer journey • Frequency of palliative care meetings • Who goes? • H/O forms used and updated? • Are you recording PPoC, concerns etc and using LCP? • Do you have educational input from specialist team?

4. Local Feedback-Questionnaires • Regionally there had been significant improvements between 2007 and 2008. • Increased numbers with a nominated lead, cancer dx list, who were getting better info from 2’ care, palliative care list. • Meetings were now monthly for majority with only small minority having < or > frequency • Meetings continued to predominantly be GPs/DNs and SPCN but 17% of surgeries also have SW • Better recording of attendance/use of h/o forms/provision of benefits advice. • Many more surgeries were making sure they were updating the h/o forms and also patients concerns/expectations and needs. • 98% of surgeries use the LCP

5. Local Feedback-PPoC Pilot • Many thanks for your involvement. • Regionally 58% wanted to remain at home, 34% wanted a nursing home/care home and the other 8% wanted to go to hospital. • 83% of patient initiated on the document died in their PPoC • Usual reason for not achieving this were care/carer issues or unexpected decline. • Very +ve feedback • With PCT, with costings, for regional rollout.

6. Symptom Control • Nausea and Vomiting. • Breathlessness. • Setting up a syringe driver.

7. Nausea and Vomiting

8. DEFINITIONS • Nausea “an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms” • Retching “rhythmic, laboured, spasmodic movements of the diaphragm and abdominal muscles” • Vomiting “forceful expulsion of gastric contents through the mouth” – complex reflex process Nausea is worse than vomiting. Occurs in 60% of people with advanced cancer.

9. ESTABLISHING the probable diagnosis in NAUSEA & VOMITING • History • Is there any relationship with food or pain – peptic ulcer? • Is it projectile or faeculant – high obstruction? • Did it start with certain medication (eg morphine, digoxin, NSAIDS)? • Do certain events or situations trigger it? (eg hospital, anxiety, chemotherapy) • ? Large volume vomit – gastric stasis • Distinguish between vomiting/expectoration/regurgitation • Psychological assessment

10. PATTERN • Nausea relieved by vomiting – gastric stasis / bowel obstruction. • Vomiting shortly after eating or drinking, with little nausea – oesophageal / mediastinal disease • Sudden unpredictable vomit, possibly worse on waking – raised intracranial pressure • Persistent nausea with little relief from vomiting – chemical / metabolic cause

11. EXAMINATION • Eyes - Possible jaundice - Examine fundi for papilloedema • Abdomen - Masses - Hepatomegaly - Distension / ascites - Presence or absence of bowel sounds • PR - If constipation suspected • Bloods - Renal & Liver function - Calcium - Specific drug levels if indicated

12. MANAGEMENT of NAUSEA and VOMITING • Review of drug regime • Cough = Antitussive • Gastritis = Reduction of gastric acid = ? Stop gastric irritant drugs • Constipation = Laxative • Raised intracranial pressure = Corticosteroid • Hypercalcaemia = IV Saline / Bisphophonate (correction is not always appropriate in a dying patient) • Ascites = ?Paracentesis R. Twycross 1997

13. MANAGING NAUSEA & VOMITINGANTI-EMETICS • Dopamine receptor antagonists D2 • Metoclopramide • Haloperidol • Histamine & muscarinic receptor antagonists H1 • Cyclizine • Prokinetic • Metoclopramide • Domperidone (does not cross BBB) • 5HT3 antagonists 5HT3 • Granisetron • Tropesitron • Ondansetron

14. MANAGING NAUSEA & VOMITINGANTI-EMETICS • Dexamethasone • ? Reduces permeability of BBB to emetogenic substances • Benzodiazepines • Amnesic, anxiolytic & sedative • Cannabinoids • AIDS / chemotherapy • Brainstem cannabinoid receptor • Octreotide • Anti-secretory properties

15. DRUG ADMINISTRATION • Oral route suitable for mild nausea. • Syringe driver or rectal route for moderate to severe nausea and / or vomiting. • Anti-emetics should be given regularly rather than PRN. • Optimise dose of anti-emetic every 24 hours.

18. DRUG ADMINISTRATIONSummary of Guidelines • After clinical evaluation, document the most likely cause(s). • Monitor the severity of nausea and vomiting. • Treat reversible causes. • Assess psychological aspects, eg anxiety. • Prescribe first-line anti-emetic for most likely cause both regularly and prn. • Optimize does of anti-emetic every 24 hours. • Reassess and change drugs by adding or substituting the second-line anti-emetic. - If little benefit, reassess the cause and change to appropriate first-line anti-emetic. - ?converting to oral route after > 3 days. - Continue indefinitely unless the cause is self-limiting.

19. Breathlessness

20. Dyspnoea • Unpleasant awareness of difficulty in breathing • Pathological when ADLs affected and associated with disabling anxiety • Resulting in : physiological behavioural responses

21. Dyspnoea • Breathlessness experienced by 70% cancer patients in last few weeks of life • Severe breathlessness affects 25% cancer patients in last week of life

22. Causes of breathlessness-Cancer • Pleural effusion • Large airway obstruction • Replacement of lung by cancer • Lymphangitis carcinomatosa • Tumour cell microemboli • Pericardial Effusion • Phrenic nerve palsy • SVC obstruction • Massive ascites • Abdominal distension • Cachexia-anorexia syndrome respiratory muscle weakness. • Chest infection

23. Causes of Breathlessness-Treatment • Pneumonectomy • Radiation induced fibrosis • Chemotherapy induced • Pneumonitis • Fibrositis • Cardiomyopathy • Progestogens • Stimulates ventilation • Increased sensitivity to carbon dioxide.

24. Causes of Breathlessness- Debility • Atelectasis • Anaemia • PE • Pneumonia • Empyema • Muscle weakness

25. Causes of Breathlessness-Concurrent • COPD • Asthma • HF • Acidosis • Fever • Pneumothorax • Panic disorder, anxiety, depression

26. Reversible causes of breathlessness! • Resp. Infection • COPD/Asthma • Hypoxia • Obstructed Bronchus/SVC • Lymphangitis Carcinomatosa • Pleural Effusion • Ascites • Pericardial Effusion • Anaemia • Cardiac Failure • PE

27. Breathlessness Cycle PANIC

28. Independent predictor of survival weeks days months Symptomatic drug treatment Non-drug treatment Correct the correctable Breathless on exertion Breathless at rest Terminal breathlessness

30. Non-Drug Therapies • Explore perception of patient and carers • Maximise the feeling of control over the breathing • Maximise functional ability • Reduce feelings of personal and social isolation.

31. Patient and Carer Perception • Meaning to patient and carer • Explore anxiety esp. fear of sudden death • Inform that not life threatening • State what is likely to/not to happen • Realistic goal setting • Help patient and carer adjust to loss of roles/abilities.

32. Maximize control • Breathing control advice • Diaphragmatic breathing • Pursed lips breathing • Relaxation techniques • Plan of action for acute episodes • Written instructions step by step • Increased confidence coping • Electric fan • Complementary therapies

33. Maximize function • Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness • Evaluation by physios/OT’s/SW to target support to need.

34. Reduce feelings of isolation • Meet others in similar situation • Day centre • Respite admissions

35. Breathlessness Clinic • Nurse lead • NNUH-Monday Afternoon • Lung cancer and Mesothelioma • Referral by GP/SPCN/Palliative Medicine team/Generalist Consultants • PBL Day Unit-Wednesday, link with NNUH.

36. Drug Treatment

37. What do I give? • Bronchodilators work well in COPD and Asthma even if nil known sensitivity. • O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension. • Usual rules regarding COPD/Hypercapnic Resp. failure apply. • Opioidsreduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness. • If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed. • If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given • Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2-5mg or Midazolam 2.5-5mg sc Repeated 4hrly as needed

38. Ongoing treatment A syringe driver should be commenced if a 2nd stat dose is needed within 24hrs • Diamorphine 10-20mg CSCI / 24hrs • Midazolam 5-20mg CSCI / 24hrs Remember to prescribe stats Review & adjust dose daily if needed

39. Terminal Breathlessness • Great fear of patients and relatives • Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI • If agitation or confusion -haloperidol or Nozinan • Some patients may brighten. • Sedation not the aim but likely due to drugs and disease.

40. Respiratory Secretions (death rattle) • Rattling noise due to secretions in hypopharynx moving with breathing • Usually occurs within days-hours of death • Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases) • Patient rarely distressed • Family commonly are distressed • Treat early • Position patient semi-prone • Suction rarely helpful

41. If secretions are present, two options. A) Hyoscine Butylbromide (Buscopan) Stat-20mg 1hrly CSCI-80-120mg/24 hrs B) Glycopyrronium Stat-0.4mg 4hrly CSCI-0.6-1.2mg /24 hrs Remember Stats at appropriate doses Review & adjust dose daily Respiratory Secretions

42. Setting up a syringe driver • www.syringedriver.co.uk • YouTube

43. Current Initiatives • EOL Drug Charts • At piloting stage • Aim to clarify and simplify prescribing at the EOL • DNACPR • “Allow a natural and dignified death” • Development of transferable DNACPR form from 1’2’3’ and visa versa • Piloting later in year • EOT Letters • Much more info, especially on late effects, anticipated problems, points of re-referral etc. • Meet next week with Tom Roques • Integrate with electronic records

44. Q and A • I am not a palliative care physician and you have an excellent resource in Gail! • Happy to answer questions.