In a palliative care emergency it is important to assess:
- The acute medical issues, and potential reversibility of the problem
- The context in terms of the patient’s disease, their expectations and wishes, and the benefits
- The burdens of any treatments which could be offered.
The patient’s recent performance state is a very important factor to assess, along with the nature and extent of the patient’s underlying disease. There is information below on the following emergencies:
While many emergencies are completely unexpected, a proportion of palliative care emergencies can be predicted from the nature and location of the disease, eg, spinal cord compression in patients with vertebral metastases, or bleeding in patients with tumours encroaching on large vessels, or bone marrow failure.
Planning ahead involves:
- sensitive counselling of patient and caregivers about the risk of a particular problem
- assessing the caregiver's’ ability to cope with a crisis and putting supports in place (eg, community nurses, transfer from home to another site of care, or mobilising other family members)
- provision of emergency medications if appropriate, and a plan which takes into account the patient’s own wishes as much as possible (eg where they wish to be cared for, whether they want to die at home).
For more guidance on managing palliative care emergencies out of hours, see Until the chemist opens: palliation from the doctor’s bag (Australian Family Physician article).
Airway obstruction
- Sub-acute presentations of large airway obstruction, often with inspiratory stridor, may be able to be actively managed. Radiotherapy or interventional procedures such as laser and stenting can give valuable palliation, if they can be accessed in a timely way.
- Obstruction of a large airway, particularly if it occurs acutely, is a frightening problem for both patients and carers. If there is little potential for reversibility, or interventions are inappropriate or not wanted, aggressive palliation may be required to maintain the patient’s comfort. Oxygen, sedation with benzodiazepines, and morphine for symptoms of respiratory distress, should all be titrated to achieve comfort.
For more detailed guidance on management of dyspnoea, see the Palliative Medicine Handbook.
Bowel obstruction
- Malignant bowel obstruction may present acutely or sub-acutely. A small proportion of patients may benefit from surgical intervention to relieve the obstruction, however they should be carefully selected. See End-of-Life / Palliative Education Resource Center (EPERC) Fast Fact on invasive treatment options in bowel obstruction.
- Many patients who are not candidates for surgery (those who are frail or with a poor performance state, who have multiple sites of obstruction or advanced disease and / or comorbidities) can be managed medically with good palliative outcomes.
- The general principles of medical management of bowel obstruction are:
- to convert medications to the parenteral route, usually subcutaneous, and provide adequate analgesia
- to use antisecretory medications to reduce the fluid load in the gut, and the associated vomiting and distress, and to avoid excessive hydration which may contribute to vomiting
- to avoid stimulant laxatives and pro-kinetic antiemetics (metoclopramide) in complete bowel obstruction as they may worsen colicky pain
- the addition of steroids has been shown to hasten the resolution of malignant bowel obstruction.
Effective medical management very rarely requires a nasogastric tube, and once nausea and vomiting start to settle, the patient can restart oral intake as they are able to tolerate it.
- For intractable symptoms, a venting percutaneous gastrostomy can be considered.
Delirium
- Delirium, or an acute confusional state, is extremely common in the palliative care setting. It is distressing for patients and their families, and is a frequent cause of admission towards the end of life. It should be regarded as a medical emergency.
- The cardinal features are:
- a fluctuating mental state
- disorganised thinking
- an abnormal state of arousal – either hyperactive and agitated, or hypoactive (NB hypoactive delirium is frequently missed, or misdiagnosed as depression or dementia)
- acute onset, in the setting of a likely causative medical condition.
In palliative care patients, delirium is frequently multi-factorial. Potentially reversible causes should be considered, and investigations undertaken as appropriate to the clinical context, especially with regard to the person's prognosis.
Medication review is important. Although minimising polypharmacy may be helpful, it is not always possible to cease the causative drigs.
The first line of treatment for delirium is a neuroleptic drug. Haloperidol is the best studied medication in this setting, although the newer atypical antipsychotics can also be used. Benzodiazepines have the potential to worsen delirium, and should be used with extreme caution.
For more information on the assessment and management of delirium, see the Palliative Medicine Handbook. For more guidance on managing delirium see also Until the chemist opens: palliation from the doctor’s bag Australian Family Physician article).
Major bleeding
- Bleeding problems in advanced cancer may have a reversible or partly reversible cause. These should be addressed as appropriate to the clinical context and the patient’s and caregivers’ wishes.
- Radiotherapy may offer good palliation of mucosal bleeding, fungating tumours, or haemoptysis Tranexamic acid may also be effective in low-grade bleeding.
- However, in the context of progressive underlying disease, such as liver failure, bone marrow failure, or local tumour invasion causing haemorrhage, it is important to consider and discuss the limits of possible supportive therapies with the patient.
- In the case of massive bleeding in advanced malignancy where resuscitation is not appropriate and the bleeding is a terminal event, the approach should be to reduce distress for all concerned, both patients and caregivers. Medications may not be able to be given in time to be effective; it may be more helpful if health professionals provide whatever comfort they are able to by staying with the patient and helping those present to stay calm.
The Palliative Medicine Handbook provides more detailed information about assessment and management of bleeding problems and management of major haemorrhage.
Spinal cord compression
- The neurological signs of spinal cord compression may be patchy and atypical, however there should be a high index of suspicion in patients with known vertebral metastases, who experience progression of back or radicular pain, or any progressive gait difficulties. Sphincter symptoms such as urinary retention may be a late feature. In assessing the patient neurologically, be aware that pain and temperature sensation are usually the sensory modalities lost first.
- By the time the patient has the classic clinical picture of spinal cord compression, it is quite likely that the condition is well established, and less likely to be reversible.
- Urgent referral for imaging (ideally by MRI scan) and radiotherapy gives the patient the best chance of regaining good neurological function, if treatment is wanted and appropriate. Having identified the possibility of a cord compression, high dose dexamethasone (8mg BD) should be given whilst investigations are arranged.
- Occasional patients may benefit from surgical decompression.
For more detailed information about assessment and management of spinal cord compression see the Palliative Medicine Handbook.
Related CareSearch pages
Breathing
Dyspnoea
Constipation
Delirium
This page was created on 26 March 2007 and is due for review in March 2009