Dignity and Symptom Control

Rachel Sheils

GSFCH Conference

10.7.2009

Dignity

state worthy of esteem and respect,

especially humanness

Ethical principles

• Autonomy• Beneficence

• Non-malfeasance

• Social justice

Symptoms in the last days

Asthenia (debility)

Anorexia

Dry mouth

Dyspnoea

Confusion

Noisy respiratory tract secretions

Pain

Restlessness / agitation

Nausea

82%

80%

70%

17 - 47%

56%

46%

46%

43%

14%

…worthy of esteem and respect…

• What makes us feel worthy of respect?

• What stops us from feeling worthy of respect?

...especially humanness…

• What makes us feel human?

• What stops us from feeling human?

Case 1- Autonomy

• PP

• 60 years old

• Motor neurone disease

• Rapid deterioration

• Living alone at home

• Independent– Maintain sitting posture

• Dependent – 8 visits/day– All cares– All mobility– Communication – scanning light writer– Oral intake – sips of cola

• Wants to stay at home until the end – at all costs

• Has the mental capacity to make this decision

• Finally agrees to be admitted when attends day hospice and appears to be dying

• Initially rallied

• Improved pain• Discharge planning – patient insistent on

going home when care arranged

• Died knowing we were trying to get her home

• Respected autonomy

• Would most of us want to be at home despite – faecal soiling– Slumping in chair if falls forwards

Case 2 Symptoms vs Side Effects

• 66 year old woman

• Ovarian cancer

• Widespread disease in abdomen

• No more surgery / chemotherapy possible

• Vomiting

• Abdominal distension

• Constipation

• Bowel obstruction

• Tried various treatments– Dexamethasone 8mg– Metoclopramide 60mg in 24 hrs in syringe

driver– Sodium docusate– Granisetron

– Not much better

• Generally deterriorating– Discussions about what was happening

• Vomiting once every 24 hours – BIG volume– Tried levomepromazine– Then cyclizine– Helped nausea but not vomiting– made her sleepy

• Pt decided to withhold levomepromazine until last few days

• Vomiting but awake

• Who knows what would make us feel more human– Vomiting, nauseated but alert– Sleepy, less aware of vomiting

Anti-emetics

• Acid - lansoprazole etc• Gastric stasis - metoclopramide/domperidone• Chemical - cyclizine, haloperidol

levomepromazine, granisetron / ondnsetron

• Cerebral - steroids, cyclizine, granisetron• Bowel - cyclizine OR metoclopramide,

granisetron, steroids• Environment• Constipation

Case 3 The pain is what the patient says

it is• 70 year old lady

• Breast cancer

• Severe lymphoedema in left arm

causing pain

• Learning disability

• Bipolar disorder

• Lived with / dependent on elderly sister

• Admitted to the hospice for pain control

• Zomorph 10mg BD

• Mirtazepine, Lithium, Sodium Valproate

• Escalating doses of Oxynorm – 80mg BD– Didn’t reduce PRN morphine use

• Crying out in pain

• Very anxious

• When nurse came – anxiety gone, still in pain– “Is this really pain or is it anxiety, a cry for help

and attention?”

• Noticed she had a history of Crohn’s disease and bowel resection– IS SHE ABSORBING THESE ORAL DRUGS

• Started a syringe driver with oxynorm

• Eventually converted to a patch

• Pain settled

• Transferred to a nursing home

• How would it feel I was vulnerable, and someone didn’t believe that:

– I was in pain

– What they were doing was helping the pain

The drugs don’t work

• Is the patient taking the drugs?

• Are they keeping them down?

• Are they absorbing them?

• Is the dose high enough?

• Is it the right pain killer?

• Syringe driver– Is it running behind?– If so, why?

Opioids

Different opioids have different strengths

Variety of routes

oral, subcutaneous, transdermal, buccal, sublingual, ??? Nebulised

Dignity

• We are all human• We are all different

• Dignity will be achieved for each individual in different ways

• Listen• Patient’s priority should be ours• Side effects vs benefits

• Any questions?