Author: Louise Free
Pain management
- Diagnose the cause and consider specific treatment (e.g. antibiotics for cellulitis, fixation of pathological fracture), combined with adjuvant therapy if indicated.
- Pain may be ‘total pain’ – a combination of psychological, social, spiritual as well as physical pain – therefore, addressing these factors is also important.
- Consider non-pharmacological management of pain alongside analgesics (e.g. heat/cool pads, TENS, complementary therapy).
- Prescribe ‘by mouth (oral), by the clock (regularly) and by the ladder’ (WHO ladder) (Figure 110.1). Adjuvants (Table 110.1) may be added at any step of the ladder.
- If prescribing opioids, co-prescribe antiemetic and laxative.
Persisting or increasing pain
- Give regular four-hourly doses of immediate-release morphine 5–10 mg PO (lower if the patient is elderly, frail, has liver disease or renal impairment) with equal doses of one-sixth of the total daily dose for breakthrough pain.
- Once a stable daily dose is established, maintenance should be with a modified release preparation.
- Review daily requirements after 24–48h and adjust the regular and breakthrough doses as needed.
- If the oral route is not possible, drugs may need to be given subcutaneously (SC) via syringe driver using the same principles.
BreathlessnessAdapted from Beynon T (2014): Guy's, King's and St Thomas's School of Medicine Clinical Teaching Resource: Palliative Care and Symptom Assessment.
Nausea and vomiting*
- Diagnose the cause and consider specific treatment.
- Consider non-pharmacological measures (e.g. reassurance, positioning, placement of a nasogastric tube).
- Ensure appropriate route of administration (parenteral if drug not being absorbed enterally).
- Use stepwise approach to management: start with most appropriate narrow-spectrum antiemetic and either switch to an alternative or add in a second if symptomatic control not achieved (Table 110.4).
Agitation and delirium
- Common causes and their management are summarised in Table 110.5. Refer also to Chapter 4.
- Terminal agitation describes the condition when a patient is dying and no clear cause can be found for agitation, or agitation is likely to be due to a number of factors which it may not be appropriate to investigate.
- Contact specialist palliative care team for advice if the patient is not settling.
Recognise the patient is dying
Signs that are commonly seen in the last few days of life include:
- Rapid deterioration in condition (often day by day) despite active treatment
- Increasing weakness – bed-bound, requiring help with personal care
- Barely able to take liquids and unable to take medicines by mouth
- Impaired concentration, muddled thinking and difficulty sustaining conversation
- Increasing drowsiness
Consider potentially reversible disorders contributing to the patient's deterioration
These include infection, acute kidney injury, hypercalcaemia, opioid toxicity, and oversedation. You must decide if treatment is appropriate and whether specialist opinion should be sought.
Communicate with the patient and their family
You should speak to the patient and those close to the patient, involving a translator if needed. Assess the patient's insight into their condition. If the patient does not have capacity, you should consult with those close to the patient and the multidisciplinary team, and make decisions in the best interests of the patient.
Make a plan of care
Elements that should be included in an individualised plan of care are summarised in Table 110.6.
- If the patient is on regular medications for symptom control but is becoming unable to swallow, or is at risk of not absorbing drugs, convert these to subcutaneous administration, for example continuous subcutaneous infusion via syringe driver.
- Ensure the patient has anticipatory subcutaneous symptom control medications written up as required. The as required opioid prescription should be one-sixth of total daily dose of regular opioid.
- Review PRN requirement after 24hrs: if three or more doses were required, consider the need for a continuous subcutaneous infusion, if not already in place.
- If the patient has reliable IV access and difficult to control symptoms (e.g. pulmonary oedema), then the continued use of IV administration (e.g. for diuretics) may be appropriate.
Keep good notes
Details of the plan of care, and summaries of conversations with the patient and family members should be documented in the medical record.
Review the patient
The patient should be seen at least daily; plans should be reviewed. Consider if specialist palliative care advice is needed.
The body of the deceased person should be cared for in accordance with their spiritual and cultural beliefs. Bereavement support should be offered to close family members.