Procedures and Investigations
- The benefits, burdens and costs of all investigations and procedures should be carefully considered for palliative care patients. The clinical judgements can sometimes be difficult, and seeking advice from a palliative care specialist may be helpful.
- Quality of life and wellbeing may should be assessed by looking at the patient, and considering their performance state, as well as by looking at scans and blood tests
- Encouraging less focus on monitoring of results (eg, scans, blood tests, tumour markers, weight) may be psychologically helpful as disease progresses - although this is sometimes difficult for both doctors and patients
- Not all problems that are diagnosed will be reversible, and reversing a problem may not always make a person feel better or improve their performance state. Treatment decisions should therefore be individualised and made in the context of the patient’s goals of care
- When a person’s prognosis is short, the benefit of investigations and treatments becomes increasingly marginal, and risks associated with hospitalisation increase
- An investigation which is unlikely to lead to any change in management of the patient is probably unnecessary, nor is it usually appropriate to investigate if a patient would not wish to be treated
- Monitoring renal function, liver function, and albumin levels intermittently can be helpful to assist in safe prescribing.
- Abdominal paracentesis to drain ascites is a relatively simple procedure that does not usually require admission to hospital. It can provide effective short-term symptom relief in people with uncomplicated ascites.
- The rate of recurrence of ascites following a tap is generally an indication of disease activity
- Frequently recurring ascites in a patient with a prognosis of months may benefit from placement of a port to allow drainage of smaller volumes more frequently at home.
Palliative Treatment of Malignant Ascites
- Thoracocentesis to drain pleural effusions can sometimes improve dyspnoea and other related symptoms, however it has a risk of pneumothorax or haemothorax. Ideally, the procedure should be done where x-ray and resuscitation equipment and the facility to insert a chest tube with underwater sealed drain are available.
- The rate of reaccumulation of an effusion following a tap is generally an indication of disease activity
- Frequently recurring pleural effusions in a patient with a prognosis of months or more may benefit from placement of a pleural catheter to allow drainage of smaller volumes more frequently at home.
Malignant Pleural Effusions Interventional Management
- Palliation of severe dyspnoea by non-invasive ventilation (BiPAP) is sometimes an option. It is used most commonly in end-stage chronic obstructive pulmonary disease (COPD). However the implications for dying patients need to be carefully considered.
Using Non-Invasive Ventilation at the End-of-Life