Never underestimate the psychological impact of a cancer diagnosis, whatever the age. Heart failure carries a worse prognosis than many cancers, yet news of its diagnosis rarely has such an impact. Whatever your assessment of a person \200\231s quality of life, they may se e things very differently \200\224 you will not know until you ask. The adverse reaction t o the diagnosis is often tied up with fears about a slow and painful death (rather than dea th itself) and careful explanation about symptom control measures may allay some concerns HOW TO Describe performance status Table 25.1 Performance status scoring 0 Active, no limitations 1 Active, but unable to carry out strenuous or heavy physical work 2 Active, spending less than half the day in bed or resting 3 Spend over half the day in bed or resting, but still able to get up 4 Bedridden AN APPROACH TO MALIGNANCY 629 An approach to malignancy Make the diagnosis \200 Even if no curative treatment is possib le, a diagnosis allows targeted symptom control and gives an idea about the likely course o f the disease and the expected prognosis Many people \201 nd \200\230not knowing what is wrong \200\231 very hard, and may \201 nd a diagnosis a relief, as it allows the future to be planned Sometimes a frail patient is obviously dying, and investigations can be an additional burde n, without hope of \201 nding reversible pathology. In this case, blind palliation of sym ptoms is the best course. This should be combined with careful explanation to the patient a nd family \200 There are many shades of gray in between these two extremes. In some cases , \201 nding multiple metastases on a scan may be enough to plan management. In others, a histological diagnosis by biopsy is required to fully balance risks and bene \201 ts of t reatment. Each individual should have bene \201 ts of diagnosis weighed up against discomf ort (and cost) of investigation Once diagnosis is made, attempt to stage the disease This allows accurate prognostication a nd gives the patient better information on which to base treatment decisions. Again, there are exceptions to this (eg the very frail who are likely to die from other causes), and eac h individual should be considered separately. Assess patient factors that will in \202 uence outcome 2 Age is not one of these factors \200 Comorbidity will adversely affect both disease prognosis and tolerance to treatment Functional status is the other main predictor \200\224 is the patient active and asymptoma tic, active but with symptoms, slowed down by symptoms or incapacitated by them? Oncologist s use performance status (see Table 25.1 ) as an indicator of functional ability and a scor e of (cid:100) 3 correlates with a median survival of 3 months. Comorbid conditions and poo rer functional status will be more common in older people, but not universal, so purely age -related treatment decisions are unwise. Utilize a specialist multidisciplinary approach Cancer care changes rapidly, and it is hard for the generalist to keep up to date, so specialist referral is usually needed. Many diff erent specialists work together in MDTs to provide cancer management, determining the best options individually. Specialist nurses often perform a coordinating role in the patient \200\231s journey through the system, providing consistent, non-threatening support, allowi ng fears to be discussed and providing practical help (eg arranging additional help at home ). Discuss decisions carefully with the patient Some patients who have led a long and healthy life (and so would poten- tially do well from therapy) may wish simply to die without being \200\230messed about \200\231. Other patients with multiple problems and poorer outlook m ay take any chance at a prolongation of life whatever the cost. 630 CHAPTER 25 Malignancy Presentation of malignancy In a cognitively intact and physically \201 t older patient wi th a malignancy, presentation is often typical \200\224 eg a breast lump, a thyroid nodule , altered bowel habit with an iron de \201 ciency anemia. In these cases, there is little dilemma \200\224 management is as for all patients with such a complaint. In the frail elderly person, the presentation is often less clear. Cancer may be found inci dentally (eg a mass on a routine CXR) or there may be a highly suggestive clinical scenario . Judging how hard to look and to what end is a common challenge in geriatric practice. Common presenting scenarios include Weight loss without apparent cause \200 Always check a dietary history (and corroborate it with family or friend), measure thyroid function, screen for depression, and assess cognitive state If there are no localizing symptoms or signs on careful history or examination, then check screening investigations (see b \200\230HOW TO Screen for ma lignancy \200\231, p.631) If these are normal, then malignancy is relatively unlikely, and dietary support with reass essment at an interval may be appropriate (see b \200\230HOW TO Manage weight loss i n older patients \200\231, p.357) Following up hints offered in a systems enquiry (eg admits to occasional loose stool) will depend on the individual patient \200\224 whether they would tolerate bo wel investigation, whether they would be \201 t for treatment if malignancy is found and, crucially, what they wish to do Elevated in \202 ammatory markers (ESR, CRP) \200 This is a relatively common scenario \200 Begin with the screening history, examination and investigations \200 An important differential diagnosis is sepsis, and this should be actively sought with cultures and appr opriate tests such as echocardiogram \200 Consider giving the patient a thermometer and t emperature chart to \201 ll in Look at joints and bones as a possible source (gout, septic arthritis, discitis, osteomyelitis, etc.) Remember diverticular and sub-diaphragmatic abscesses \200 Have a low threshold for think ing of endocarditis (see b \200\230Overview of infection in older people \200\231, p.608) Vasculitides (especially see b \200\230Giant cell arteritis \200\231, p.474) should be con sidered and a trial of steroids may be appropriate, even if the history is not convincing, but remember to check response and rethink the diagnosis if the blood results do not normal ize A CT scan of the thorax, abdomen and pelvis (looking for lymphadenopathy) may be justi \201 ed if the patient is otherwise \201 t and has signi \201 cantly abnormal tests Chasing mildly elevated markers in the frail elderly person is often unrewarding, and can b e very distressing for the patient. If initial assessment is unhelpful, watchful waiting my be a valid approach PRESENTATION OF MALIGNANCY 631 Anemia \200 Iron de \201 ciency anemia should always raise the query of gastrointestinal malignancy, and investigation tailored to the individual situation (see b \200\230Iron de \201 ciency anemia: diagnosis \200\231, p.454) \200 A normochromic norm ocytic anemia with normal haematinics is rather more dif \201 cult \200\224 it may repres ent anything from mild myelo \201 brosis or renal failure to disseminated malignancy Screening history, examination, and tests should be performed. If normal, then a decision about suitability for bone marrow biopsy needs to be made on an ind ividual patient basis. Does the patient have a reasonable life expectancy? Would treatments (eg chemotherapy) be appropriate if hematological malignancy was con \201 rmed? HOW TO Screen for malignancy History Should include: \200 Dietary history \200 Mood assessment \200 History of fev ers and night sweats \200 Travel history \200 HIV risk factor assessment (if appropriat e) \200 Full systems enquiry (especially meticulous enquiry into gastrointestinal symptoms and postmenopausal bleeding) Examination Full examination required, including: \200 Lymphadenopathy \200 Skin nodule s or rashes (expose the patient fully) \200 ENT \200 Male external genitalia (testicula r masses) \200 Female breast and pelvic examination \200 Rectal examination \200 Thyr oid examination Investigations \200 FBC with \201 lm; and haematinics \200 Urea and e lectrolytes \200 LFTs \200 Calcium and phosphate \200 Glucose \200 TFTs \200 ESR and CRP \200 Urine and blood electrophoresis \200 Urinalysis (dipstick for blood) \200 CXR \200 Fecal occult bloods (if anemic) \200 PSA in men 2Tumor markers have a role i n monitoring of established disease, but are controversial in screening \200\224 false pos itive rates are high. 632 CHAPTER 25 Malignancy Treating malignancy in older people Overall, the response to treatment is as good in \201 t elderly people as in younger patients. Frailty and comorbidity will alter tolerance to t reatments more than age. There are specialist MDTs for cancer care that should help to ensu re that the most appropriate treatment modalities are considered. Any treatment should be d iscussed (where possible) with the patient, out- lining bene \201 ts, potential harm, and practical considerations (such as travel- ling daily to the hospital for a course of treatm ent, or supplying support for activities of daily living when weakened by therapy). 2Decisi ons about cancer treatment should not be based on chrono- logical age, rather on biological age, functional status, and the presence of comorbid conditions. The patient should be at the center of the decision-making process \200\224 decisions are rarely clear-cut and require balancing of the side effects of therapy against potential ben e \201 ts. Frank discussion of what to expect should facilitate patient-led decisions, and there will be a wide variety of choices. Some older people will wish to avoid intervention s while others will accept a high level of discomfort for the chance of a few extra months of life. Ask the patient. \200 Surgery can be well tolerated if the patient is pre-select ed and receives optimal attention before, during, and after an operation. Curative operatio ns should always be considered regardless of age and even palliative surgery may be appropr iate, eg in a frail octogenarian, defunctioning colostomy for a sigmoid tumor may be prefer able to constant diarrhea that causes skin breakdown Radiotherapy is well tolerated by \201 t elderly people, and side effects may be acceptab le to even the more frail if the bene \201 ts are suf \201 cient. It is often pragmatic i ssues such as prolonged daily travel to the hospital that is the most dif \201 cult for an older person, perhaps worse than the treatment itself. Hospital transportation may mean an early start, a late \201 nish, and an uncomfortable journey. These problems should be di scussed prior to treatment and psychosocial support offered where possible Hormonal therapy is often very useful in older people, being well tolerated and effective. It forms the mainstay of treatment for postmenopausal women with breast cancer and for men with prostate cancer. Its role is in disease control, not cure, but is often provides very effective palliation until they die from another cause Chemotherapy agents are improving all the time, being better tolerated and more effective. Cardiac comorbidity can cause problems with the amount of \202 uid that is required. Soci al isolation can make transportation to and from treatments and managing the side effects d if \201 cult. Recognition of this and provision of support is essential if treatment is co nsidered TREATING MALIGNANCY IN OLDER PEOPLE 633 HOW TO Manage symptomatic hypercalcaemia Older patients often present with acute confusion and constipation; the classical symptoms of thirst, itch, and bone pain may be less prominent. 2Important to check serum calcium for any unexplained confusion or constipation. 2Beware hypoalbuminaemia which can mask a high calcium \200\224 always check the corrected calcium level If corrected calcium is high, send off a PTH level and screen for tumors. Commonest maligna nt causes include myeloma and carcinomatosis with bone secondaries (eg prostate or breast) and squamous carcinoma of the lung (where calcitonin-like substances are excreted). Commone st benign cause is hyperparathyroidism. Management 1. Rehydration with intravenous \202 uids \200\224 aim for 3 \200\2234L/day ( but more cautious in heart failure) 2. Once patient is rehydrated, give furosemide 20 \200\22340mg with each bag as this promotes urinary calcium excretion and prevents \202 uid overload 3. Monitor calcium daily and adjust treatment In malignant disease , consider: \200 Intravenous bisphosphonates, eg pamidronate \200 Steroids, eg prednisolone 30mg/day or dexamethasone 2 \200\2234g/day Work by slowing tumor turnover. Can cause confusion or hyperglycaemia Speci \201 c tumor therapy (eg antiandrogens for prostate carcinoma, radiotherapy for myel oma) but localized therapies seldom in \202 uence serum calcium levels There is a group of patients with malignant hypercalcaemia who respond to treatment but relapse as soon as iv \202 uids are stopped. If all avenues of t reatment have been tried a palliative approach is sometimes appropriate in which the calciu m is allowed to rise and only symptoms are treated In hyperparathyroidism , consider parathyroidectomy \200 Management of the confused hyper calcaemic patient : Can be particularly dif \201 cult especially as patients often pull out iv cannulae Consider opiate analgesia (there may be bone pain which the patient cannot tell you about) Benzodiazepine sedation may be required 634 CHAPTER 25 Malignancy Cancer with an unknown primary Cancer with an unknown primary makes up around 2 % of all ma lignancy diagnoses, but this proportion increases with age because older patients may have less speci \201 c and less aggressive presentation. They also tend to seek medical attenti on less promptly. Presentation is with metastases, usually in liver, lungs, bones, or lymph nodes. Finding metastases during investigation for vague symptoms or when looking into more speci \201 c problems (such as bone pain, abnormal liver function tests, breathlessness, enlarge d lymph nodes etc.) is a commonly encountered problem in geriatric practice, and a structur ed approach to management is essential. Etiology \200 After biopsy, 70 % of cancers with an unknown primary are is found to be ad enocarcinoma, 15 \200\22320 % poorly differentiated carcinomas, and 10 % poorly differentia ted adenocarcinoma The primary becomes clear in only 20 % after investigation \200 At postmortem, 40 \200 \22350 % are found to be pancreatic, hepatobiliary or lung, and most of the remainder are f rom the gastrointestinal tract while 20 \200\22330 % still do not have a primary identi \201 ed Approach to investigation Sometimes, once metastatic cancer is identi \201 ed, no further investigations are appropriate \200\224 eg if the patient is frail and asymptomatic, or if death is very near. In most cases, however, there is something to be gained by determining the primary and extent of metastases \200\224 ranging from (very rare) cure, through prol ongation of life (eg for hormonally sensitive tumors), to the targeted palliation of sympto ms. Treatment has been greatly advanced by obtaining biopsy samples and using immunohistochemic al techniques to improve diagnosis and recognizing clinical syndromes that can predict resp onses to certain chemotherapy combinations. Arrange the following: Careful history and examination (including thyroid, breast, pelvis in women and a rectal ex amination) looking for hints of the primary Blood tests, including FBC, U,C + E, LFTs, calcium, phosphate, LDH, and PSA. Tumor markers (CEA, CA 15-3, CA 19-9, CA125, A-fetoprotein, B-human chorionic gonadotrophin ) are not useful in diagnosis or prognosis, but may be used to monitor response to any trea tment Urinalysis \200 Fecal occult bloods ( \227 3) \200 CXR \200 Consider thyroid ultraso und \200 Consider mammogram (in women) \200 Abdominal CT scan \200\224 identi \201 es the primary site in 10 \200\22335 % and shows additional metastatic sites 2Further radiological or endoscopic investigation is rarely helpful, often uncomfortable an d a poor use of resources. CANCER WITH AN UNKNOWN PRIMARY 635 Biopsy specimens \200 Should usually be obtained if possible (radiology may show the best site). Information from biopsy assists greatly in further management. \200 Occasionally there will be histological hints as to the primary source (eg signet rings in the glandular cells indicating gastric cancer), but more commonly there is not enough differentiation to allow diagnosis. \200 Immunohistochemical stains have h elped considerably, and there are speci \201 c stains for prostate, thyroid, and bronchogenic adenocarcinoma and stains high ly suggestive of a breast primary. Combinations of stains (eg CEA, CA 19-9, CA 125, cytokeratins, breast cancer antigen) may r eveal patterns that suggest the primary but these are less speci \201 c. Prognosis Prognosis is better if: \200 Fewer metastases \200 Metastases only in lymph n odes and soft tissues (less good if bones or liver involved) Certain histological sub-types \200 Female patient, with few comorbidities, and a good pe rformance status \200 Normal serum lactate dehydrogenase level 2It is unrelated to age. Treatment options Women with peritoneal metastases \200 Usually ovarian or other gynecolo gical cancer \200 Some show extremely good response to chemotherapy, with 15 \200\22320 % long-term remission in papillary serous carcinoma Women with axillary lymph node metastases \200 Usually breast cancer \200 Investigate w ith mammogram and MRI breasts if negative \200 Even if no breast lesion found, treat as b reast cancer in the standard way Involvement of axillary nodes only means potentially curable disease (by mastectomy, node clearance, and radiotherapy) Bone metastases \200 In men these are usually from prostate cancer (especially if sclerot ic or blastic metastases) and elevated PSA may con \201 rm this. Standard hormonal treatme nt for prostate cancer often provides effective palliation Lung cancer is the other common cause, with liver, kidney, thyroid, and colon being rarer primary sources Single metastatic focus in brain, lung, adrenal, liver, bone or lymph node \200 Occasiona lly actually an unusual primary \200 Usually will metastasize to other sites fairly quick ly \200 Consider surgical resection \200 Radiotherapy for a solitary brain metastasis c an occasionally produce long-term survival 636 CHAPTER 25 Malignancy None of the above \200 Empirical chemotherapy (based on histology and clinical syndrome) produces some response in around 40 % , and a good response in around 10 % Overall, there is up to 20 % 3-year survival with treatment (median survival around 10 months) 637 Chapter 26 Death and dying Breaking bad news 638 HOW TO Break bad news 639 Bereavement 640 HOW TO Promote a \200\230healthy bereavement \200\231 641 Palliative care 642 Symptom control in the terminally ill 644 HOW TO Prescribe a subcutaneous infusion for palliative care 646 Documentation after death 648 Other issues after death 650 The coroner 651 638 CHAPTER 26 Death and dying Breaking bad news Geriatricians frequently break bad news. No matter how old and frail the patient, the news can always come as a devastating blow. Equally, news that may seem bad ma y be taken well \200\224 someone who has felt unwell for ages may welcome an explanation, even if it means a terminal diagnosis. Sometimes they will have been expecting worse ( \200 \230I \200\231ve had a stroke? Thank God it isn \200\231t cancer \200\231). 2Each case need s to be considered individually and carefully modi \201 ed as reactions become apparent. Who should be told bad news? \200 Information about a patient \200\231s diagnosis and pro gnosis belong to the patient, and that individual has a right to know. The paternalistic te ndency to \200\230protect \200\231 a patient or their relatives from bad news is now large ly obsolete, but some patients and relatives still believe this exists and this may need to be corrected Very often, fears that an older person will not cope with bad news are unfounded. They may not have asked questions because they are not culturally used to qu izzing doctors, but will often have an idea that something is wrong. Anxieties about remain ing family members (particularly spouses) can be addressed once everyone knows a patient \200\231s diagnosis and management plan. Open dialog may ease distress Equally, there are some older people who simply do not wish to know details about diagnosis and prognosis, preferring to trust others to make decisions for them. It is inappropriate to force information on such patients and crucial to identify them. Approaches range from b lunt questioning \200\224 \200\230If you turn out to have something serious, are you the sort of person who likes to know exactly what is going on? \200\231 to a more subtle line \200\224 \200\230We have some test results back, and your daughter is keen to talk to me a bout them. Would you like to know about them too? \200\231 The response to this is usually informative \200\224 either \200\230Yes, of course I want to know \200\231 or \200\230Oh , well I \200\231d rather let my daughter deal with all that \200\231 Well-meaning relatives (usually children, who are more used to challenging authority) may be more proactive in seeking information than the patient, and t hen try to shield their relative from the truth, believing that they would not be able to c ope. In such situations, try to avoid giving information to relatives \201 rst \200\224 explain that you cannot discuss it with them without the patient \200\231s permission. Be s ympathetic \200\224 these wishes are usually born from genuine concern. Explore why they d on \200\231t want news told, and encourage reality \200\224 the patient knows that they ar e unwell and must have had thoughts about what is wrong. Point out that it becomes almost i mpossible to continue to hide a diagnosis from a patient in a deteriorating condition and t hat such an approach can set up major con \202 icts between family and carers. Be open \200\224 tell the relative that you are going to talk to the patient, and promise discretio n (ie you will not force unwanted information). A joint meeting can be valuable if the pati ent agrees. They may be right, and the patient does not want to be told, but establish this for yourself \201 rst and always get permission from the patient before disclosing detai ls to anyone else BREAKING BAD NEWS 639 HOW TO Break bad news 1. Make an appointment and ensure that there will be no interruptions 2. Ensure that you are up to date on all the latest information \200\224 about the disease itself and the latest patient condition. (Have you seen them that morning ?) 3. Talk in pleasant, homely surroundings away from busy clinical areas 4. Ensure that you are appropriately dressed (eg not covered in blood from a failed resuscitation attempt) 5. Suggest that family members or friends come along to support 6. Invite other members of the MDT (usually a nurse) who are involved in the patient \200\231s care 7. Begin with introductions and context ( \200\230I am Dr Brown, the doctor in charge of yo ur mother \200\231s care since arriving in the hospital. This is Staff Nurse Green. I alrea dy know Mrs. Jones but perhaps I could also know who everyone else is? \200\231). It is som etimes useful to make some \200\230ice-breaking \200\231 non-medical comments (eg \200 \230How was the journey? \200\231), but do not be \202 ippant 8. Establish what is already known ( \200\230A lot has happened here today \200\224 perhap s you could begin by telling me what you already know? \200\231 or in a non-acute setting \200\230When did you last speak to a doctor? \200\231) 9. Set the scene and give a \200 \230warning shot \200\231. ( \200\230Your mother has been unwell for some time now, and whe n she came in today she had become much more seriously ill \200\231 or \200\230I \200\231m afraid I have some bad news \200\231) 10. Use simple jargon-free language to describe events, giving \200\230bite- sized \200\231 chunks of information, gauging comprehension and response as you go 11. Avoid euphemisms \200\224 say \200\230dead \200\231 or \200\230cancer \200\231 if th at is what you mean. Avoid false reassurances and platitudes 12. Allow time for the news to sink in \200\224 long silences may be necessary; try not to \201 ll them because you are uncomfortable 13. Allow time for emoti onal reactions, and reassure in verbal and non-verbal ways that this is an acceptable and n ormal response 14. Encourage questions 15. Do not be afraid to show your own emotions, while maintaining professionalism \200\224 strive for genuine empathy 16. Summarize and clarify understanding if possible. If you feel that the message has been lost or misinterpreted, ask them to summarize what they have been told, al lowing reinforcement and correction. Complex medical terms are usefully written down to tak e away and show to relatives or look up 17. Someone should stay for as long as is needed, and offer opportunity for further meeting to clarify questions that will come up later 18. Document your meeting carefully in the medical notes 640 CHAPTER 26 Death and dying Bereavement Common experience in older people \200\224 causes huge psychological mor- bidi ty. A fourth of older widowers/widows develop clinical anxiety and/ or depression in the \201 rst year. 2The grieving process is amenable to positive and negative in \202 uences, so awareness of those at risk can help target care. Normal stages of grief Not linear \200\224 often go back and forth between stages. \200 Shock/denial : lasts from minutes to days. Longer if unexpected death. Resolves as reality is accepted Pining/searching : feel sad, angry, guilty, vulnerable; urge to look back and search for th e dead person; restless, irritable, and tearful. Loss of appetite and weight. Poor short-te rm memory and concentration. Resolved by feeling pain and expressing sadness. May be hamper ed by social or cultural pressures to behave in a certain way Disorganization/despair : feel life has no meaning. Tend to relive events and try to put it right. Common to experience hallucinations of the deceased when falling asleep (reassure t hat this is normal). Resolves as adjust to the new reality without the deceased Reorganization : begin to look forward and explore a new life without the deceased. Find th ings to carry forward into the future from the past. May feel guilt and need reassurance. P eriod of adjustment Recurrence : grief may recur on anniversaries, birthdays, etc. Abnormal grief Hard to de \201 ne as everyone is different (both individual and cultural v aria- bility) and the process cannot be prescribed. In general, weight is regained by 3 \200\2234 months, interest is regained after several more months, and the beginnings of rec overy have usually been recognized by 2 years. Risk factors for abnormal grief These include: \200 Sudden or unexpected loss \200 Low self-esteem or low social support \200 Prior mental illness (especially depression) \200 Multiple prior bereavements \200 Ambivalent or dependent relationship with the deceased \200 Having cared for the deceased in their \201 nal illness for more than 6 months Having fewer opportunities for developing new interests and relationships after the death Although older people are generally more accepting of death than younger people, they commo nly have a number of these risk factors (eg an 80-year-old man who has cared for his dement ed wife for 3 years prior to her death, is likely to have had an ambivalent relationship as well as being her carer. He may have limited social support and opportunity for alternativ e social contacts). 2Older widowers have the highest rate of suicide among all groups of be reaved persons BEREAVEMENT 641 HOW TO Promote a \200\230healthy bereavement \200\231 \200 Identify those at risk of abnormal grief (see b \200\230Risk factors for abnormal grief \200\231, p.640) Encourage seeing the body after death if wished \200 Encourage involvement in funeral arr angements \200 A visit by the GP after death to answer questions, or a meeting with the hospital team can be very helpful Good social support initially is crucial and professional/voluntary groups (eg CRUSE at M w ww.crusebereavementcare.org.uk ) or counselors can be helpful if family/friends are not pre sent There needs to be permission for \200\230time out \200\231 and reassurance that they are experiencing a normal reaction As time goes on, setting small goals for progressive change can structure recovery For the confused, older patient, repeated explanations, and supported involvement in the fu neral and visiting the grave have been shown to reduce repetitive questioning about the whe reabouts of the deceased. 642 CHAPTER 26 Death and dying Palliative care Death is inevitable. Physicians should acknowledge their limitations, not s eeing every death as a personal or system failure. Society has a misper- ception that medic al technology can always postpone death \200\224 this should be addressed, and death portr ayed when appropriate as a natural and inevitable end. Palliative care is concerned with the holistic management of a patient in whom death is lik ely to be soon and where curative treatments are no longer possible. It aims to help the pa tient (and relatives) come to terms with death while optimizing the quality of the time lef t. It involves an MDT approach, with attention to relief of physical symptoms and to social , psychological, spiritual, and family support. Traditionally used in cases of incurable cancer (where a diagnosis has often been made and a prognosis given), the approach is valuable in many other situations. Death from, eg end-s tage heart failure is as predictable as death from cancer, yet application of palliative ca re measures is less frequent. Discussing impending death with a patient is often dif \201 cult for doctor and patient, but it allows the goals to shift from hopeless (patient cure) to realistic and achievable (planning a good death). With the complexity of illness in olde r people, deciding when death is inevitable can be dif \201 cult and there is often a degr ee of uncertainty \200\224 not least about timescale \200\224 but the rewards to the pati ent and carers are many. Most people die not in a hospice, but in other settings \200\224 sometimes an acute hospit al but more typically in a community-based facility (eg a community hospital or care home) or their own home. The challenge that health professionals often face is to deliver the mor e desirable characteristics of hospice care in a less specialist setting. That is usually a chievable \200\224 primary and secondary care teams have huge experience and skills in car ing for the dying patient, reinforced when necessary by specialist palliative care teams. B ut patients and families often need reassurance that exemplary end-of-life care can be deli vered outside the hospice setting, in all but the most challenging cases. General principles of palliative care \200 All symptoms should be evaluated and a diagnos is made, based on probability and pattern recognition Explanation of cause and planned treatment empowers the patient and keeps expectations realistic Treatment involves correcting what can be corrected (eg treating oral candida that is contr ibuting to anorexia), counseling to help patients accept the limitations imposed by the dis ease (eg a patient with COPD may never be able to walk in the garden, but supplying a wheel chair will allow them to be taken), and drugs to control symptoms Treatment is planned for each individual with careful attention to detail. Effects are moni tored closely, and treatment discontinued if ineffective PALLIATIVE CARE 643 At the very end \200 Basic care should always be continued (warmth, comfort, shelter, freedom from pain, cleanliness, symptom control, offer of oral nutrition, and hydration) \200\230Arti \201 cial \200\231 nutrition and hydration (ie that which bypasses swallowin g) is considered by many to be a treatment, and as such may be withheld Simplify medications. Use subcutaneous routes where appropriate \200 Communication with t he patient and family becomes even more important \200\224 continue regular visits, even if there is no apparent change Ask nurses and family about concerns they have (eg pain on turning) \200 Enlist help from specialist palliative care teams if symptom control is dif \201 cult A proactive, positive approach at this time can transform the experience of losing a relative The principle of double effect Sometimes treatments given to relieve symptoms can worsen the underlying disease, eg opiate s given for pain also cause respiratory depression. It is not a duty of the physician to prolong life at all costs. The British Medical Associa tion states: \200\230A single act having two possible foreseen effects, one good and one h armful, it is not always morally prohibited if the harmful effect is not intended. \200\231 In other words, if the primary aim of the morphine is to relieve pain, and a secondary (fo reseen) consequence of this is respiratory depression and death, then the primary aim justi \201 es the secondary consequence. Good communication with family and other members of the team ensures that everyone understa nds the rationale behind a treatment plan. The Liverpool Care Pathway for the Dying Patient (LCP) is used increasingly in the UK. It l ays out systematically the elements of care that may form part of best quality care of a pa tient in the last hours or few days of life. Such a pathway may be appropriate when the MDT (often comprising an experienced nurse and d octor) is agreed that a patient will inevitably die in the near future (ie that reversible causes have been excluded). Where there is doubt, a second opinion is often helpful. 644 CHAPTER 26 Death and dying Symptom control in the terminally ill 2Is delivered usually by general primary and secondar y care teams, not by palliative care specialists. Pain \200 Use the analgesia ladder, starting with non-opioids (paracetamol, NSAIDs) \200 Next, add weak opioids (codeine, dihydrocodeine, tramadol); escalate the dose then replac e with strong opioids (eg morphine slow release). Give regularly and treat all side effects (nausea, constipation) Aim to give orally if possible, but consider subcutaneous bolus/infusion, transdermal or rectal routes if necessary Identify likely cause(s) \200\224 there may be different pains with different causes in one individual \200\224 and target treatment to cause Neuropathic pain is often opioid responsive, but antidepressants and anticonvulsants can be added Treat muscle spasm with physiotherapy, heat, antispasmodics and benzodiazepines Treat nerve compression pain with steroids Nausea and vomiting \200 Identify cause \200\224 is it reversible? (eg medication, hyper calcaemia, bowel obstruction) Give small portions of palatable food, avoid strong smells \200 Use regular antiemetics: Metoclopramide is indicated when there is gastritis, stasis and functional bowel obstruction Cyclizine is used with raised intracranial pressure and functional bowel obstruction Haloperidol treats chemical causes such as hypercalcaemia \200 Domperidone \200 Ondanse tron Constipation \200 Start with a stimulant laxative (eg senna) or stool softener if not on opiates depending on stool characteristics Opiates cause decreased peristalsis; a stimulant laxative is usually appropriate Danthron-containing stimulant laxatives are banned in all but terminal care, as they may be carcinogenic. They also cause skin burns so are usually avoided in incontinent patients Suppositories, enemas or digital evacuation may be needed SYMPTOM CONTROL IN THE TERMINALLY ILL 645 Anorexia \200 Normal in advanced cancer, and other conditions as death approaches \200 Family concerns may be the main problem \200\224 they may feel their relative is giving up Deal with this directly \200\224 eating more will not alter the outlook and pressurizing the patient can make them miserable Decrease medications that cause nausea or anorexia (opiates, SSRIs) \200 Give good mouth care \200 Help with feeding if weak \200 Offer frequent small meals \200 Prokinetics (eg metoclopramide) or steroids (prednisolone, medroxyprogesterone) may help Dyspnoea \200 Treat cause (transfuse for anemia, drain effusion, etc.) \200 A terrifyin g symptom \200\224 plan approach for how to deal with an attack without panicking Oxygen can help, as can an anxiolytic or opiates, fresh air or fans, and physiotherapy if mucus retention is an issue Confusion \200 Identify cause (infection, drugs, withdrawal from alcohol, electrolyte imbalances) Nurse in calm, well-lit environment. Relatives can often help with reorientation Drugs (eg haloperidol, benzodiazepines) should be used only when non-drug measures have proven ineffective Dehydration \200 Dying patients drink less (weakness, nausea, decreased level of consciousness) but often do not feel thirsty Good mouth care is all that is required where the decreased intake is part of the dying pro cess and the patient is not distressed by thirst \200 Reassure relatives (and staff) that it is the disease that is killing the patient, not the dehydration \200\230Death rattle \200\231 \200 The patient is usually unaware. Reassure the family o f this \200 If excess secretion is causing distress or discomfort to the patient or the f amily, use hyoscine butylbromide, hyoscine hydrobromide, or glycopyrronium (available subcu taneously or as patches) Further reading British National Formulary. Prescribing in the Palliative Care Section . M www.bnf.org . HOW TO Prescribe a subcutaneous infusion for palliative care Is the subcutaneous route appropriate? Use regular oral route where possible \200 Consider when: Vomiting/nausea/malabsorption \200 Dif \201 culty swallowing, eg near the end or if semi -conscious Is the patent already on an opiate? Calculate the current total dose given per 24hr (including prn administration) \200 Has this been adequate? (Ask nurses, family, and patient) \200 Con vert the oral opiate dose to an equivalent parental dose (see BNF ), eg morphine sulfate MR 20mg bd is equivalent to diamorphine 15mg s/c per 24hr If starting strong opiates de novo , start low (eg 1mg/hr morphine with allowances on the prn side for breakthrough pain) Morphine is cheaper and more readily available, but diamorphine is more soluble so can be g iven in a smaller infusion volume and is less likely to precipitate with multiple other dru gs. Morphine has about 2/3 potency of diamorphine (cid:2) Are there any other symptoms? Other agents can be added to the pump \200 Eg metoclopramide for nausea (30 \200\22360mg/ 24hr) Hyoscine hydrobromide for respiratory secretions (0.6 \200\2232.4mg/24hr) \200 Haloperido l for nausea, restlessness and agitation (5 \200\22315mg/24hr) \200 Midazolam for sedatio n (10 \200\22360mg/24hr)