Palliation
palliative care – there are 2 major issues to be discusses, working out a plan with the patient and symptom control.
- break bad news to the patient
- Discern goals for care
- Treatment of SSx
Breaking Bad News
- prepare for the discussion
- set up a suitable environment
- begin the discussion by finding out what the patient and/or family understand
- determine how they will comprehend new information best and how much they want to know
- provide needed new knowledge accordingly
- allow for emotional responses
- share plans for the next steps in care
Determine goals for care
- ensure that information is as complete as reasonably possible and understood by all relevant parties
- explore what the patient and/or family are hoping for while identifying relevant and realistic goals
- share all the options with the patient and family
- respond with empathy as they adjust to declining expectations
- make a plan, emphasizing what can be done toward the realistic goals
- follow through with the plan
- review and revise this plan periodically, considering at every encounter whether the goals of care should be reviewed with the patient and/or family.
- If a patient or family member has difficulty letting go of an unrealistic goal, suggest that, while hoping for the best, it is still prudent to have a plan for other outcomes as well.
Treatment of Symptoms:
| Symptom | Non-Pharmacological | Pharmacological |
| Distressing shortness of breath at rest | Positioning Reassurance | If hypoxic: Seek local guidance on safe oxygen use. Stat dose: – Morphine 2.5mg subcut injection + Midazolam 2.5mg subcut injection. – If eGFR <30mL/min, or patient is >65 years old or frail: Reduce to 1.25mg for both medications. PRN dose for breakthrough pain/anxiety: – Morphine 2.5mg subcut injection + Midazolam 2.5mg subcut injection every 1-2 hours as needed. – If eGFR <30mL/min, or patient is >65 years old or frail: Reduce to 1.25mg for both medications. Continuous subcut infusion (if available): – Morphine 10mg + Midazolam 10mg over 24 hours. If eGFR <30mL/min, or patient is >65 years old or frail: – Reduce to Morphine 5mg + Midazolam 5mg over 24 hours. If continuous infusion unavailable: – Morphine 2.5mg subcut injection every 4 hours. – Clonazepam 0.5mg sublingual drops (5 drops) every 12 hours. PRN medications: Always ensure availability of: – Morphine 2.5mg subcut injection + Midazolam 2.5mg subcut injection every 1-2 hours as needed. – If eGFR <30mL/min, or patient is >65 years old or frail: Reduce to 1.25mg for both medications. |
| Agitation | If mild, encourage relaxation, breathing techniques | If severe: Midazolam 2.5mg subcut injection PRN 1-2 hourly. If eGFR <30mL/min or >65 years of age or frail Midazolam 1.25mg subcut injection PRN 1-2 hourly. If more than 4 PRN doses required, consider a continuous subcut infusion (starting dose Midazolam 10mg over 24 hours. If eGFR <30mL/min or >65years of age or frail: reduce to 5mg over 24 hours) or Clonazepam 0.5mg sublingual drops (5 drops) 12-hourly. Always ensure PRN medications are available. Based on the above, prescribe Midazolam 2.5mg subcut injection PRN 1-2 hourly. |
| Pain | Positioning | If mild and able to swallow: Paracetamol 1gm QID If severe: commence opiod analgesia as summarised for severe breathlessness. |
| Cough | If mild and able to swallow: Pholcodine 10mg orally QID. If severe and continuous infusion is available: – Morphine 10mg subcut infusion over 24 hours. If eGFR <30mL/min or patient is >65 years old or frail: – Morphine 5mg subcut infusion over 24 hours. If continuous infusion is not available: – Morphine 2.5mg subcut injection every 4 hours. If eGFR <30mL/min or patient is >65 years old or frail: – Morphine 1.25mg subcut injection every 4 hours. PRN medications: Always ensure availability of: – Morphine 2.5mg subcut injection every 1-2 hours as needed. If eGFR <30mL/min or patient is >65 years old or frail: – Morphine 1.25mg subcut injection every 1-2 hours as needed. | |
| Fever | Cool face washers Ice to suck if tolerated | If able to swallow: – Paracetamol 1g oral 6 hourly PRN orally or PRN Diclofenac 75mg oral 8 hourly PRN (max dose 200mg daily) If unable to swallow: Paracetamol 1gm intravenous injection 6 hourly PRN or Ketorolac 10mg sub cut injection stat followed by 10-30 mg subcut injection 8 hourly (max 90mg daily). |
| DeliriumMild and not distressed Re-orientate to time and place ReassuranceEnsure not in urinary retention | If the patient is not settling or becoming more distressed: add Haloperidol 0.5-1mg subcut injection 4 hourly PRN. | |
| Respiratory tract secretions Repositioning the patient from side to side in a semi-upright position is recommended Suctioning of the oropharynx is very rarely recommended The most important non-pharmacological intervention is to preemptively counsel carers, families and other health professionals that noisy breathing is part of dying process. | Trial Glycopyrronium (or Hyoscine Butlybromide if Glycopyrronium is not available) for 24 hours and cease if no change in noisy breathing observed. Start with Glycopyrronium 0.2 mg subcut injection 4 hourly PRN. If severe and continuous subcut infusion available: – Glycopyrronium 1.2 mg subcut infusion over 24 hours. If Glycopyrronium not available: – Start with Hyoscine Butlybromide 20mg subcut injection 4 hourly PRN. If severe and continuous subcut infusion available: – consider Hyoscine Butlybromide 120 mg subcut infusion over 24 hours. | |
