Emergencies

Key points

  • A palliative care emergency is a sudden and life-threatening change in a patient’s condition. Assessment includes:
    • The medical context, particularly potential reversibility of the problem
    • What the patients’ status would most likely be following any treatment that could be offered
    • The person’s recent performance state, the extent of their underlying disease, and key prognostic indicators
    • The burdens of any treatments that could be offered
    • The patient’s wishes when informed of the potential benefits and burdens of treatment.
  • Emergencies may be completely unexpected, but some can be predicted from the nature and location of the patient’s disease eg,
    • Spinal cord compression in patients with vertebral metastases 
    • Bowel obstruction in patients with peritoneal disease 
    • Bleeding in patients with tumours encroaching on large vessels or who have bone marrow failure.
  • Planning ahead for predictable problems is possible. It involves:
    • Sensitive preparation of patient and family carers 
    • Assessing family carers’ ability to cope with a crisis
    • Putting appropriate supports in place (eg, community nurses, personal alarm systems, plans for transfer from home to another site of care, or mobilising other family members)
    • Organise dark coloured towels to be available for the patient who is at risk of a major bleed
    • Provision of emergency medications - these should be left in the patients’ home with written orders, or as a crisis order (with medications dispensed and available if an inpatient or residential aged care resident), and a plan which takes into account the patient’s own wishes where possible (eg, where they wish to be cared for, whether they want to die at home or not, the likely impact on others around the patient).
  • Out of hours strategies for palliative care emergencies may sometimes require transfer to a hospital. However providing an ambulance plan for the patient may mean they can receive very effective symptom management in the home in a crisis situation, without initiation of resuscitation or the necessity to transfer to an emergency department. 
  • Contact the local palliative care service for emergency management advice at any time. Palliative care teams provide a 24 hour on call service, and have considerable experience in dealing with these emergencies.
  • 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 may give valuable palliation, if they can be accessed in a timely way.
  • Obstruction of a large airway, particularly if it occurs acutely, is frightening for patients and carers. If there is little potential for reversablity, or interventions are inappropriate, unavailable, or not wanted, or too slow to take effect, aggressive palliation may be required to keep the person comfortable.
  • Sedation using benzodiazepines and morphine for symptoms of respiratory distress is often appropriate. These should be rapidly titrated to achieve sedation.
    Management of dyspnoea and terminal breathlessness

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 may give valuable palliation, if they can be accessed in a timely way.
  • ​Obstruction of a large airway, particularly if it occurs acutely, is frightening for patients and carers. If there is little potential for reversability, or interventions are inappropriate, unavailable, or not wanted, or too slow to take effect, aggressive palliation may be required to keep the person comfortable.
  • Sedation using benzodiazepines and morphine for symptoms of respiratory distress is often appropriate. These should be rapidly titrated to achieve sedation.
    See Management of dyspnoea and terminal breathlessness

Bowel obstruction

  • Malignant bowel obstruction may present acutely or sub-acutely. A small proportion of patients can benefit from surgical intervention to relieve the obstruction, however they should be carefully selected and should have an excellent performance status (ideally scoring ECOG 0-1 or modified Karnofsky scale 90-100) (35kb pdf).
Most patients are not candidates for surgery (those who are frail or with a poor performance state, have multiple sites of obstruction or advanced disease and/or comorbidities) but can nonetheless be managed medically with good palliative outcomes.
See Management of malignant bowel obstruction
  • The general principles of medical management of bowel obstruction are:
    • To use antisecretory medications (eg, hyoscine butylbromide or ranitidine) 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 be aware of potential for stimulant laxatives and pro-kinetic antiemetics (metoclopramide) in complete bowel obstruction to worsen colicky pain
    • The addition of steroids (eg, subcutaneous dexamethasone) may have a role in the resolution of malignant bowel obstruction, and can help relieve nausea
    • Effective medical management very rarely requires a nasogastric tube, although initial decompression may be helpful, and once nausea and vomiting start to settle, the patient can restart fluid intake if they are able to tolerate it
    • For intractable symptoms, if a patient has a life expectancy of a few weeks or more, 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 of delirium are:
    • A fluctuating mental state
    • Disorganised thinking
    • An abnormal state of arousal - either hyperactive and agitated, or hypoactive 
    • Acute onset.

Hypoactive delirium is frequently missed, or misdiagnosed as depression or dementia

  • In palliative care patients, delirium is frequently multifactorial. 
    • Potentially reversible causes should be considered, and investigations undertaken as appropriate to the clinical context, especially with regard to the person's prognosis and overall performance status.
    • Medication review is important. Although reducing polypharmacy may be helpful, it is not always possible to cease the causative drug/s.
If pharmacological treatment is required, an antipsychotic should be tried first. Haloperidol is the best studied medication in this setting. Benzodiazepines have the potential to worsen delirium, and should be used with caution if there is a need for sedation.
See Management of delirium

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 family carers’ wishes. 
See Management of bleeding and haemorrhage
  • Radiotherapy may offer good palliation of mucosal bleeding, fungating tumours, or haemoptysis.
  • Tranexamic acid may be effective in low-grade bleeding.
  • 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.
  • Massive bleeding may occur 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.
    See Massive terminal 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 or faecal incontinence 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. 

The best predictor of functional outcome from radiotherapy for spinal cord compression is the degree of neurological deficit at the time treatment is started.

  • Having identified the possibility of a spinal cord compression, high dose dexamethasone (8mg BD) should be given whilst investigations are arranged.
  • 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.
  • Some patients with a previously good performance state may benefit from surgical decompression and a neurosurgical review should be arranged urgently.
    See Clinical pathway for managing metastatic spinal cord compression

Seizures

  • Patients who have a history of seizures from any cause are at risk if they can no longer take oral anticonvulsants - either because of vomiting or difficulty swallowing.
  • A long acting benzodiazepine is usually effective in this situation if given at an appropriate dose. Clonazepam can be used either subcutaneously or sublingually and is therefore a common choice. The patient and carers should be advised that this is likely to be more sedating when it is initiated than their usual anti-epileptic medications.
  • Strategies for managing difficult to control seizures will require the ready availability of a fast acting benzodiazepine such as midazolam.
Seizures that are unable to be controlled with benzodiazepines should be urgently discussed with a palliative care service.
See Managing seizures

For guidance on managing palliative care emergencies out of hours, see Until the chemist opens: palliation from the doctor’s bag (236kb pdf) 

Peer reviewed guidelines - Assessing and prescribing in palliative care emergencies

Palliative Care Guidelines Plus
From: Palliative Care Adult Network Guidelines, UK.

Clinical pathway - For managing metastatic spinal cord compression

National Institute for Health and Care Excellence (NICE)

This online pathway links to detailed information related to each step in the process of assessing and treating a patient with metastatic spinal cord compression.

From: National Institute for Health and Care Excellence, UK

Last updated 21 February 2017