End of Life CareEnd of Life CareDr Anant SachdevGPSI Palliative Medicine
07976 [email protected]
Learning objectivesLearning objectivesUrological Cancer symptoms in
End of LifeIdentify those at risk from the
following 2 serious clinical scenarios
Understand treatment optionsRefer appropriatelyGeneral principles
SymptomsSymptoms• Pain• Malaise, Fatigue & Cachexia• GI: Poor appetite, nausea• Weight loss• Bleeding• Incontinence• Delirium • Spinal Cord Compression• Hypercalcaemia
Malignant spinal cord Malignant spinal cord compressioncompression
First contact is usually primary health care team!
Common Significant impact on QOL and
survivalRequires rapid decision making
IncidenceIncidence
5% of all cancers in final 2 years Presenting feature
ACUP, NHL, myeloma and lung Decreases with age, but 90% are
>50yrs Depends on primary site
60% are lung, prostate or breastNHL, Multiple myeloma and renal (5-10%)
Colorectal, ACUP and sarcomas
PathophysiologyPathophysiology
Vertebral body mass – anterior compression
Vertebral body collapseDirect tumour growth through
vertebral neural foramen (lymphoma)
Metastases in epidural space (rare)
Clinical featuresClinical featuresLocalisation Localisation
60-80% thoracic spine15-30% lumbosacral<10% cervical50% have more than 1 level
Clinical featuresClinical featuresPain – early sign
Up to 95% for 8/52 localised then radicular Worse when
recumbent valsalva manoevre Neck flexion/SLR
Motor deficits – late sign 60-85% weakness at diagnosis 2/3 non ambulatory at diagnosis Thoracic>lumbosacral
Clinical featuresClinical features
Sensory deficits – late sign 40-90% at diagnosis Sensory level 1-5 segments below lesion Lhermitte’s sign
Autonomic deficits – late sign Urinary retention most common. 50% catheter dependent at diagnosis. Unlikely to be an isolated sign.
InvestigationInvestigationPlain Xray
False negative 17%
Bone scan Back pain + negative bone scan & plain xray
unlikely to have SCC
CT MyelographyMRI
Sensitivity 93%, specificity 97% Diagnostic accuracy 95% Multi level common therefore image entire
spine
Spinal Cord CompressionSpinal Cord CompressionTreatmentTreatment Corticosteroids
8mg BD (morning and lunchtime) and PPI cover Random daily BMs
Bed rest and pressure area care Bowel care RT (early as poss)
1# for pain mgt if no poss of recovery; 5# for treatment
Surgery Early rehab
Recurrent Spinal Cord CompressionRecurrent Spinal Cord Compression
10% pt will develop local recurrence
25-50% pts surviving > 1 yr will experience local relapse.
Mgt – surgery (may be inappropriate); Re-irradiation; supportive and palliative care
Spinal Cord CompressionSpinal Cord CompressionPrognosisPrognosisMedian survival is 3-6 months If ambulatory pre compression 8-10
monthsNon-ambulatory pre compression 2-4
monthsPrimary tumour myeloma / lymphoma – 6-9
monthsPrimary tumour lung – 2-3 months
Almost all patients have recurrence within 3 years
Referral guidelinesReferral guidelinesImmediate investigation (same day)
◦ New onset weakness +/- sensory symptoms +/- autonomic symptoms
◦ Prescribe steroid + PPI
Urgent investigation◦ Persistent severe back pain/nerve root pain without neurological
symptoms if: High risk group Thoracic pain Recumbent pain Exacerbated by valsalva manoevre/Lhermitte’s sign
No investigation◦ Too frail for treatment◦ Very short life expectancy (weeks)◦ Already irradiated to tolerance or unfit for neurosurgery◦ So disabled, cord compression will not effect overall
mobility
Key pointsKey pointsCommonPoor outcome unless early
diagnosisPain is the keySubtle motor changesNeurological deficit is too lateBe aware of:
High risk groups Clinical features
Hypercalcaemia in Advanced Hypercalcaemia in Advanced CancerCancer The Commonest life-threatening
metabolic emergency associated with advanced cancer
A condition which is usually amenable to treatment
If untreated distressing and fatal Always consider when there is
deterioration for no clear cause
Definition?
HypercalcaemiaHypercalcaemia
Defined as corrected plasma calcium >2.6mmol/l
Significant symptoms usually develop above >3.0
Levels > 4.0 are fatal if untreated in a few days
HypercalcaemiaHypercalcaemia
Incidence◦10 – 20% of all cancer patients◦Up to 20% of patients develop
hypercalcaemia without bone metastases
◦Common cancers: bronchial, breast, myeloma, prostate
◦Rare in gastric/colorectal cancer
HypercalcaemiaHypercalcaemia
Cause / risk factors:◦Bone metastases◦PTHrP – secreting tumours e.g. Lung Cancer
◦Dehydration, renal impairment◦Tamoxifen flare
HypercalcaemiaHypercalcaemia
Pathogenesis:◦ Increased bone resorption (osteolysis) and systemic
release of humoral hypercalcaemic factors◦ Calcium is released from bone, and in addition
there is may be a decrease in excretion of urinary calcium
Calcium release from bone by production of locally active substances produced by bone metastases: ◦ Parathyroid hormone related peptide, ◦ Ectopic parathyroid secretion◦ Tumour mediated calcitriol production◦ (Some may occur with or without bone mets.)
• Anorexia• Weight loss• Nausea and vomiting• Constipation / ileus
General
• Dehydration• Polydipsia• Polyuria• Pruritis
Recognising Hypercalcaemia
Neurological
• Fatigue • Confusion
• Myopathy • Seizures
• Psychosis • Coma
Cardiac
• Bradycardia
• Atrial arrhythmias
• Ventricular arrhythmias
• Cardiac asystole
• Death
GI
PrognosisPrognosis
Indicates disseminated Disease
Poor prognosis 80% die within 1
year
Median survival is 3 to 4 months
Hypercalcaemia likely to recur
HypercalcaemiaHypercalcaemia
Treatment may not be necessary if:
the patient is very near to death
or there are no symptoms
distressing the patient
Treatments of Treatments of HypercalcaemiaHypercalcaemia
All treatments involve the correction of
serum calcium levels, which results in a
marked decrease in symptoms
Rehydration Bisphosphonates Steroids
Treatments of Treatments of HypercalcaemiaHypercalcaemia
Rehydration: Dehydration due to vomiting and polyuria, large volume will lower calcium levels, note fluid-overload! 2-3 L/day usually Avoid concomitant use of diuretics, Vitamin A and D which promote hypercalcaemia
Treatments of Treatments of HypercalcaemiaHypercalcaemia
Steroids:◦Have been shown to inhibit
osteoclast activity and calcium absorption from the gut in vitro
◦Limited to haematological and Breast malignancies when oral prednisolone 40-100mg/day is usually effective
Treatments of Treatments of HypercalcaemiaHypercalcaemia
Bisphosphonates
◦Reduce bone resorption by inhibiting osteoclast activity
◦Highly effective◦But take 48 hours to be effective◦Mainstay of hypercalcaemia
treatment◦Further benefit is that of reduction
of bone pain due to metastases
TreatmentTreatment
Dehydration should be corrected with iv fluids
Most common choices of drug IV:◦ Zolendronic Acid: 4mg over 15 minutes◦ Disodium Pamidronate: 30-90 mg over 2-4
hoursEffect seen after 4 - 7 daysLasts 2-4 weeks, many patients have
monthly infusions20% patients with hypercalcaemia will
be resistant to infusion therapy
General EOL principles to General EOL principles to follow:follow:
Review patient regularly - holistically Get District nurses involved early, others eg Macmillan Inform Out of Hours, and practice team - & update! Ascertain PPOC Review symptoms and drugs Communicate well with patient, family and carers
◦ Explain management of crises, ◦ whom to contact, ◦ use of 999, ◦ possible pathway for illness and symptoms expected
when deteriorates,◦ ethical issues : nutrition, hydration, use of ab,
oxygen,◦ supportive measures available, financial help◦ (DS1500)
Consider Just-in-Case medication Consider DNACPR statement
All of the above - Adopt the Liverpool Care Pathway for holistic management of the dying patient
Top Related