Ascitic and pleural taps
Paracentesis is a relatively simple procedure which can provide effective short term symptom relief using minimal equipment in people with uncomplicated ascites. Careful evaluation is needed to quantify volume of ascites, and ensure loculation is not present.
Thoracocentesis has a risk of pneumothorax or haemothorax. It should only be carried out with the immediate availability of x-ray and resuscitation equipment, and the facility to insert a chest tube with underwater sealed drain if required.
Online guidance on how to perform an ascitic or pleural tap is contained in the Palliative Medicine Handbook.
Managing syringe drivers
A syringe driver is simply another method of administering medications when a person is no longer able to swallow. There is no intrinsic advantage of infusions over other methods of medication administration. Syringe drivers are battery operated pumps for delivering continuous infusions, which usually run over 24 hours. Palliative Care Australia has a report on subcutaneous infusion devices.
Two different models of syringe driver are available; the green MS26 model is the one which should be routinely used, and rates should be calculated over 24 hours. When staff are unfamiliar with the equipment, or if both types of pumps are in use, or staff members use different ways to calculate the infusion rate in syringe drivers, there is a risk of potentially fatal medication error. Procedures should be standardised to minimise this possibility.
Appendix 2 of the Therapeutic Guidelines – Palliative Care describes the use of syringe drivers and other infusion devices.
Reviewing medications according to changing patient needs
The deteriorating patient
(eg, largely bedbound, more time asleep, declining or fluctuating oral intake, declining or fluctuating conscious state).
- Think about polypharmacy: co-morbid medications (eg, for ischaemic heart disease, osteoporosis, etc) can be reduced and stopped as progression occurs.
- Think about the route of administration of medications - losing the ability to swallow is an inevitable part of deterioration.
- Sometimes it is not possible to replace important medications usually taken orally, for example:
- Aperients: consider judicious use of suppositories or other PR management
- Adjuvant analgesics: residual pain may need to be covered by an increase in opioids.
- Antidepressants.
- However, anticonvulsants for seizure control can be replaced with clonazepam 0.5 to 1mg subcutaneously bd, and the dose increased if seizures occur.
The actively dying patient
- Consider which medications are contributing to the patient's comfort and cease all others.
- Consider what observations are needed and cease all others (BSLs, vital signs etc).
- Consider possible symptoms which may arise in the last days and hours, and ensure that a supply of medication is available to cover that problem. The main concerns are likely to be:
Medications or prescriptions to cover these problems may be left for patients at home or in a nursing home, so that if problems arise, orders can be acted on quickly. Planning ahead, and good communication between the GP and community nurses, or the staff of residential aged care facilities, can prevent or quickly resolve many crises.
Finding out more
This page was created on 26 March 2007 and is due for review in March 2009