Palliative care emergencies
Subtopic:
Palliative care emergencies
Palliative care emergencies are defined as abrupt deteriorations in a patient’s health status that demand prompt and urgent medical attention.
A rapid and thorough assessment is essential for achieving positive outcomes in these situations.
Key Considerations in Managing Palliative Care Emergencies:
Nature of the Urgent Situation: It is crucial to understand the specific medical crisis that is occurring. This involves accurately identifying the presenting emergency.
Patient’s General Health Status: Evaluate the patient’s overall physical condition and well-being at the time of the emergency. This provides context for the severity and impact of the emergency.
Disease Stage and Prognosis: Consider the progression of the patient’s underlying illness and their expected future health trajectory. This helps in determining the appropriateness and goals of intervention.
Available Treatment Options: Determine what medical treatments are realistically accessible and obtainable in the current circumstances. This focuses on practical treatment possibilities.
Treatment Affordability: Assess the financial implications and cost-effectiveness of potential treatments. This takes into account the economic realities of care.
Treatment Efficacy and Side Effects: Evaluate the anticipated effectiveness of available treatments alongside their potential adverse reactions. This balances potential benefits against risks.
Patient’s Desires: Prioritize and respect the patient’s personal preferences and wishes regarding their care and treatment choices. Patient autonomy is paramount.
Caregiver’s Desires: Take into account the preferences and perspectives of the patient’s caregiver(s) as part of the decision-making process. Caregiver input is valuable and important.
Emergency Assessment Process:
Problem Identification: Accurately diagnose the specific medical issue causing the emergency. A precise diagnosis is the first step in effective management.
Problem Reversibility: Determine if the underlying medical problem is potentially reversible or treatable. Assessing reversibility guides treatment strategy.
Impact on Patient Condition: Evaluate how resolving the emergency will influence the patient’s overall health status and well-being. Consider the potential benefits of intervention.
Quality of Life Improvement via Intervention: Assess whether active intervention has the potential to maintain or improve the patient’s quality of life. Focus on enhancing well-being, not just survival.
Treatment Accessibility and Cost: Confirm that the selected treatment option is both readily available and financially feasible for the patient. Practical considerations are crucial.
Patient Preferences: Reiterate and honor the patient’s expressed wishes and values in the emergency care plan. Patient-centered care is key.
Caregiver Preferences: Reiterate and consider the caregiver’s input and preferences as part of the collaborative decision-making process. Acknowledge the caregiver’s role and perspective.
Types of Palliative Care Emergencies:
Severe Uncontrolled Pain
Spinal Cord Compression (SCC)
Hypercalcaemia
Haemorrhage
Superior Vena Cava Obstruction (SVCO)
Severe Uncontrolled Pain
Pain management is paramount in palliative care to ensure patient comfort and well-being. Severe uncontrolled pain, whether acute or chronic (pain lasting over 3 months), requires immediate and urgent intervention.
Understanding Acute Pain
Acute pain can manifest as anticipatory, procedural, acute-on-chronic, or breakthrough pain. It’s frequently associated with cancer complications and can evolve into chronic pain if not effectively managed. Timely management of acute pain is crucial to prevent pain progression and alleviate patient distress.
Assessment
Determine Potential Cause: Rapidly identify the underlying cause of the pain to guide the most appropriate pain relief strategy.
Utilize PQRST Assessment: Evaluate the pain using the PQRST method, focusing on:
Provoking/Palliative factors
Quality of pain
Radiation/Region of pain
Severity of pain (using Numerical Rating Scale (NRS), Visual Analog Scale (VAS), or Faces Scale for children under 8)
Timing of pain
Assess Pain in Different States: Evaluate pain intensity separately when the patient is at rest and during movement, as pain levels can fluctuate with activity.
Management
Severe uncontrolled pain (whether at initial presentation or a sudden increase in existing pain) is an emergency. Continuous patient attention is necessary until pain is effectively controlled. Rapidly establishing the potential cause is key to administering appropriate analgesia.
Immediate Goal:
To reduce pain intensity and enable patient rest. Pain reduction facilitates further assessment and management planning.
Pharmacological Approach:
Initial Dose Administration: Administer an immediate (“stat”) dose of oral morphine, typically 5-10mg. For patients already on morphine, provide a breakthrough/rescue dose equal to their regular 4-hourly dose, given immediately.
Response Evaluation: Assess the patient’s pain response 30 minutes after the initial dose.
Dose Repetition (if needed): If pain persists unrelieved, repeat the initial morphine dose.
Alternative Route Consideration: If oral administration is not feasible or ineffective, consider subcutaneous (SC) or intravenous (IV) routes.
Regular Morphine Dose Adjustment: Titrate (adjust) the regular morphine dose based on the patient’s response. Be prepared to significantly increase the dose, potentially by 100% or more, if required to achieve pain control.
Ongoing Review: Regularly reassess pain levels and treatment effectiveness. Be prepared to modify the management plan if the current approach is not providing adequate relief.
Addressing Specific Causes
Severe uncontrolled pain can be associated with various underlying conditions, including:
Bone metastases
Visceral cancer
Thoracic cancer
Soft tissue and bone cancer
Central or peripheral nervous system involvement
Procedure or treatment-related pain
Cancer-related complications
Thoroughly evaluate and address any specific factors contributing to the sudden onset or worsening of pain to tailor management effectively.s
Spinal Cord Compression (SCC)
Spinal cord compression (SCC) is a critical medical emergency involving the compression of the spinal cord, resulting in neurological dysfunction.
The most frequent cause of SCC is vertebral metastases, where cancer spreads to the vertebrae, invading the epidural space and pressing on the spinal cord. SCC is commonly observed in advanced malignancies, particularly cancers of the breast, lung, prostate, kidney, lymphoma, myeloma, and sarcoma.
In approximately 20% of cases, spinal cord compression occurs at multiple vertebral levels. The thoracic spine is the most common site (70%), followed by the lumbar spine (20%), and the cervical spine (10%). It’s crucial to note that below the L2 vertebral level, compression affects the cauda equina (nerve roots), not the spinal cord itself.
Clinical Presentation
Back pain is the most typical initial symptom of SCC, occurring in over 90% of cases. Pain is often the earliest indicator. The pain can manifest in various ways:
Bony pain: Resulting from vertebral metastases directly affecting the bone.
Radicular pain: Nerve root compression, causing radiating pain.
Diffuse band-like pain: A less localized, band-like sensation around the torso.
Unpleasant sensations: Abnormal sensations below the level of compression.
Pain is frequently exacerbated by activities that increase pressure on the spine, such as straining, coughing, or sneezing. Patients may also describe sharp, shooting pains or electric shock-like sensations radiating down the legs. Percussion (tapping) of the vertebrae near the compression site may elicit tenderness, though its absence doesn’t rule out SCC in suggestive cases.
Rapidly escalating back pain that is severe and difficult to manage should always raise strong suspicion for SCC.
Limb weakness typically follows escalating back pain in progressive SCC. Patients often initially describe their legs as feeling “heavy” or uncoordinated. The combination of escalating back pain and leg heaviness is sufficient to warrant considering and treating for SCC.
Physical Examination Findings
Tenderness upon palpation of the spine
Motor weakness in the limbs
Reduced muscle tone
Decreased rectal sphincter tone
Diminished reflexes (early stage)
Sensory loss with a defined sensory level
Diagnostic Investigations
Plain X-ray: Can reveal vertebral metastases or vertebral collapse at the affected level in approximately 80% of cases. However, a normal x-ray does not exclude the diagnosis.
MRI (Magnetic Resonance Imaging): MRI is the preferred imaging modality for diagnosing SCC when available, offering detailed visualization of the spinal cord and surrounding structures.
CT Scan or Myelogram: CT scans or myelograms (though less common now) can also be valuable diagnostic tools.
Prognostic Indicators
The patient’s neurological status at the start of treatment is the most critical factor determining prognosis in SCC. Less neurological damage at presentation is associated with a better chance of recovery.
Patients with paraparesis (weakness) generally have a better prognosis than those with paraplegia (paralysis).
Loss of bowel or bladder sphincter control is a negative prognostic sign.
Recovery is more likely after compression of the cauda equina compared to the spinal cord proper.
Management of SCC
Urgent Radiotherapy Referral: Immediate referral for radiotherapy is essential. Radiotherapy fields typically encompass 1-2 vertebral levels above and below the site of compression.
Exclude Infection: Rule out infectious causes like tuberculosis (TB), as these may require different treatment and could delay appropriate SCC management.
High-Dose Steroids: Urgent treatment often involves high-dose corticosteroids, such as dexamethasone (16-24mg orally or IV). Steroids reduce inflammation and edema around the tumor and spinal cord, potentially improving leg weakness and providing time for radiotherapy to take effect.
Steroid Tapering: If the patient responds well to radiotherapy and steroids, gradually taper down the dexamethasone dose every 3 days to the lowest maintenance dose that maintains neurological stability and pain control.
Steroid Discontinuation: In some cases, steroids can be completely discontinued after radiotherapy without recurrence or worsening of SCC symptoms.
Analgesia Titration: Aggressively titrate analgesics, particularly morphine if the patient is already taking it. A substantial dose increase is often needed in the initial stages of SCC management, concurrent with steroid and radiotherapy initiation.
Incontinence and Bowel Care: Pay close attention to bowel and bladder function. Patients with urinary retention may require catheterization.
Bowel Management: Patients with complete cord compression unresponsive to treatment may require regular enemas or manual rectal evacuation for bowel management.
Pressure Sore Prevention: Implement measures to prevent pressure sores, such as assisting the patient to sit up periodically and ensuring regular repositioning.
Caregiver Education: Educate family members on how to provide appropriate care, including repositioning and pressure area management.
Realistic Prognosis Communication: Provide both the patient and family with clear and honest information about SCC, its effects, and a realistic assessment of recovery prospects.
Early Recovery Window: If neurological recovery is going to occur, it typically begins relatively early in treatment, often within days to weeks.
Truthful Prognosis After Immobility: After weeks of immobility without improvement, recovery becomes increasingly unlikely. It is kinder to be truthful with the patient about this prognosis rather than fostering false hope.
Avoid False Hope: Resist the urge to create false hope, even with good intentions. Unrealistic expectations can lead to unnecessary expense (e.g., costly physiotherapy), patient frustration, and disappointment when recovery does not occur, potentially damaging the patient-provider relationship if the patient feels misled.