Palliative care aims to improve quality of life for patients with life-limiting illnesses through early identification and treatment of pain and other symptoms. Palliative care takes a holistic approach addressing physical, psychosocial and spiritual needs. Dyspnea, or breathlessness, is a common and distressing symptom experienced by over 50% of hospice patients. A thorough history and assessment of dyspnea is important to identify potential causes and guide treatment options. Both non-pharmacological and pharmacological interventions can provide relief, including opioids, benzodiazepines, oxygen, bronchodilators, and corticosteroids. Active management of dyspnea is important during the last hours of life to minimize suffering.

1. Palliative Symptom Management

2. Content
• Introduction to Palliative Care
– Definition
– Scope of palliative care
– Specialist and generalist palliative care
– Service outline
– End of Life Programmes and recognition of dying
• Symptom Management
– Dyspnoea
– Nausea & Vomiting

3. What is Palliative Care?
Palliative Care is interdisciplinary care whose
approach improves the quality of life for patients and
their families facing the problems associated with
life-threatening illness, through the prevention and
relief of suffering by means of early identification
and impeccable assessment and treatment of pain
and other problems, physical, psychosocial and
spiritual.
World Health Organisation 2002

4. Scope of palliative care
• A holistic approach (physical, psychological, spiritual,
social) to patients with:
Malignant diseases
Other non-curable, life-limiting or terminal illnesses
– MND
– MS, Parkinson’s Disease
– Advanced organ failure (cardiac, respiratory, renal)
– Dementia, Learning disability

5. The Palliative Care Approach
• focus on quality of life
• whole - person approach
• care for person and significant others
• respect for autonomy
• communication

6. Palliative Care – Overview of Services
• Multidisciplinary specialty
– Doctors, nurses, Physiotherapy, Occupational Therapy,
Social work, Chaplain, Volunteers, Fundraisers
• General roles – all health care professionals [Community and
secondary care]
• Holistic vs strictly ‘Medical’
• Patient centred approach

7. • Specialist roles [Hospital, Hospice, Community]
• NHS and Voluntary Sector
• Specialist Palliative Care has a range of Services available to
patients;
• Inpatient (Hospices)
• Outpatient (Hospices, Hospital Teams)
• Day Hospice
• Specialist clinics (Dyspnoea, Lymphoedema, Complementary
therapies)
• Marie Curie Nurses and Hospice at Home

8. Specialist Palliative Care Units
(Hospice Units)
• Full MDT
• Symptom management
• Rehabilitation
• Family or patient psychological distress in relation
to death or loss
• Respite care
• Terminal care
• Day care
• Bereavement service
• Other therapies
• Research & Education

9. Cure/Life-prolonging
Intent
Palliative/
Comfort Intent
D
E
A
T
H
“Active
Treatment”
Palliative
Care
D
E
A
T
H
EVOLVING MODEL OF PALLIATIVE CARE
previously
now

10. • End of Life
Programmes
• Recognition
of dying

11. Top 5 regrets of the dying
• Peoples’ first regret is that they haven’t been true to themselves
and have lived the life others expected them to live rather than the
life they wanted to live. They haven’t “lived their dreams.”
• Next, and I knew this was coming, people—actually mainly men—
wished that they hadn’t worked so hard.
• The third regret people have is that they haven’t had the courage to
express their feelings.
• People’s fourth regret is that they haven’t stayed in touch with
friends.
• Finally, people regretted that they hadn’t allowed themselves to be
happier.
Richard Smith – Contemplating my deathbed - 19 Aug, 10 – BMJ Blogs
“Through Twitter I have received a list of the five things that people most
commonly regret when dying.”
http://ezinearticles.com/?Top-Five-Regrets-of-the-dying&id=3268063

12. Planning a good death - BBC 2006
http://www.bbc.co.uk/health/support/includes/planning_a_good_death.pdf

13. Practical check list for a good death
- from the BBC document
• Recorded clearly all my personal details
• Drawn up will and have it checked with solicitor
• Consider writing a living will
• Make arrangements for care of children
• Ensure someone knows my wishes re future care
• Discussed thoughts re funeral

14. Emotional checklist for a good death
- from the BBC document
• Talked about what dying means with family/friends
• Agreed with family/friends what I would want to
know about a serious illness and what medical
treatment(s) I would refuse
• Thought seriously about people with whom I have
unfinished business
• Talked to at least one of those people
• Begin recording memories of my life for future

15. Dying trajectories
(Lynn & Adamson Rand - Health White Paper 2003)

16. Effects on patient if diagnosis of dying not made
(BMJ 2003)
uncontrolled
symptoms
Cultural/spiritual issues
not addressed
Conflicting messages
Loss of trust
(patient and carers)
Unaware that death
is imminent
Lack of dignity
?Inappropriate CPR

17. UK End of life programme
Patient Choice
• Gold Standards Framework
– GP proactive care
• Preferred place of care
• Care of the dying pathway
Keep patients where
they want to be [Community].
Do they want to
be at home?
Know what to do.
Do it well.
Make a diagnosis?

18. Physiotherapist
O.T.Chaplain
Pharmacist
Social worker
Family
Carer
Other
Specialists
Clin. Nurse Spec.
Community/
Church
Dentist
District Nurse
Psychologist
Pall. Med. Cons.
Oncologist
Patient
General Practitioner
Surgeon

19. Most common symptoms seen in
patients with advanced disease.
SYMPTOM % SYMPTOM LAST YEAR IN LIFE
Pain 84
Loss of appetite 71
Nausea / Vomiting 51
Sleeplessness 51
Dyspnoea 47
Constipation 47
Depression 38
Loss of bladder control 37

20. SIGNS OF IMPENDING DEATH
• Rapidly increasing weakness and fatigue
• The patient is usually bed bound
• Decreasing intake of food and fluids
• Difficulty in swallowing
• Decreasing level of consciousness•

21. Preparing for the Last Hours
• Make sure the family is prepared:
– Is there an advanced directive ?
– Has a DNAR order been established?
• Educate the family
– What to expect as the end nears
– The signs of imminent death (Cheyne-Stokes
respiration, skin mottling, loss of consciousness)

22. Reassess Treatments
Consider discontinuing
– Redundant oral medications
– Intravenous or subcutaneous (hypodermoclysis) fluids
– Oxygen (if patient is unconscious or finds oxygen
administration uncomfortable. )
– Invasive monitoring
• Care of the dying pathway

23. The Last Hours
If patient is unable to swallow:
Prepare for alternative administration routes for
essential drugs
Sub-cut injections (SC)
Syringe driver (CSCI – Continuous sub-cut infusion)
Rectal administration
(Transdermal- if already in use)

24. Dealing with “Death Rattle”
• Reassure family, visitors that choking is unlikely
• Try gentle oro-pharyngeal suctioning
• Avoid deep or frequent suctioning
• If severe, consider drugs
• Most families are reassured with an
explanation

25. “Death Rattle”
Pharmacological Management
Scopolamine (hyoscine hydrobromide) SC:
400mcg (0.4 mg) SC (onset 1–3 minutes)
Duration of action: ± 1 hour
May worsen delirium or agitation
Glycopyrrolate:
200mcg (0.2 mg) SC or IV
onset is 1 min,
Duration of action: ± 6 hours

26. Pronouncement and Certification
of Death
• Notify family.
• Do not ask family or other loved ones to leave the
room while you examine the patient.
• Confirm absence of pulse and heart and lung sounds.
Confirm dilatation of pupils.
• Document these.

27. “Medicine is not about conquering disease
and death, but about alleviation of
suffering, minimising harm, smoothing the
painful journey of man to the grave.”
Strabanek

28. BREATHLESSNESS

29. Content
• Introduction - physiology of normal breathing
• Causes of dyspnoea
• Management
• History, examination and investigations
• Specific Treatments
• General Non-pharmacological approaches
• General Pharmacological approaches
• Management of terminal breathlessness

30. Respiration

31. Physiology of normal breathing
• Central
medulla
(CO2)
• Peripheral
(O2)
Mechanical receptors in intercostal muscles, diaphragm,
stretch receptors in airways

32. Physiology of normal breathing
• With malignant lung disease dyspnoea is often due
to distortion and stimulation of the mechanical
receptors, and blood gases are often normal
• Some patients with COPD have a blunted response to
CO2 due to chronic retention – caution is required if
using oxygen therapy as these patients are
dependent on a hypoxic drive for breathing
• Dyspnoea occurs in 50% of hospice patients

33. Dyspnoea
• Breathlessness or
dyspnoea – a subjective
experience of breathing
discomfort
• Not to be confused with
tachypnoea
• Can be distressing for
patients and carers

34. Cycle of increasing panic and breathlessness
Breathlessness
Fear of dying.
Lack of understanding
Increased anxiety
panic

35. Causes of dyspnoea – related to cancer
• Lung tumour causing obstruction
• Lung infiltration
• Lymphangiitis carcinomatosis
• Pleural effusion (malignant)
• SVC obstruction
• Pericardial effusion
• Ascites
• Chest wall pain

36. Assessment of Dyspnea
• Pattern
– Intermittent
– Continuous
– Acute intense episodes
• Triggers
• Associated emotions

37. Dyspnoea – treat underlying causes
• Tumour – chemo/radiation
• Infections – antibiotics
• Anaemia – transfusion
• Fluid overload – diuretics
• Effusions – draining / pleurodesis
• Bronchospasms – bronchodilators
• Inflammation – steroids
• Cough – asthma, sinusitis, reflux, steroids
• Chest wall pain – radiotherapy, nerve blocks, analgesia
• Retained secretions

38. Pulmonary and nodal metastases

39. Gross ascites causing SOB- elevation
and limitation of movement of diaphragm

40. Lung “white-out” secondary to lung collapse

41. Copyright ©1997 BMJ Publishing Group Ltd.
Davis, C. L BMJ 1997;315:931-934
Pleuropericardial effusion

42. Pulmonary infiltration – miliary pattern

43. CT showing
pleural thickening.
PET positive.
“Hot pleural plaques”
implying malignancy -
mesothelioma

44. Causes of dyspnoea – treatment related
• Surgery
• Radiation induced fibrosis
• Chemotherapy-pneumonitis, Interstitial
fibrosis
• Drugs e.g NSAIDS

45. Causes of dyspnoea – related to debility
• Infection
• Anaemia
• Fatigue
• Muscle weakness
• Pulmonary embolism

46. Other causes of dyspnoea
• COPD/Asthma
• Cardiac failure
• Arrhythmias
• Pneumothorax
• Blocked tracheostomy
• Acidosis
Also:
• Anxiety/fear/distress

47. Assessment of Dyspnoea
The patient’s assessment of their dyspnoea is the most
reliable---take a good HISTORY.
• Clinical signs don’t always correlate with the symptom
experience
• Dyspnoea is NOT necessarily related to the respiratory
rate or oxygen saturation
• Do not use oxygen saturation as a sole measure of
Dyspnoea
• The palliation of dyspnoea depends on the cause and
the patient’s prognosis’ (Palliative Adult Network
Guidelines, 2011)

48. Assessment of Dyspnoea
• Pattern
– Intermittent
– Continuous
– Acute intense episodes
• Triggers
• Alleviating factors
• Associated emotions
• Use scales to measure and monitor
• Investigations as needed

49. Non-Pharmacological Management
• Use a fan
• Position: lean forward, head up
• Physiotherapy / OT input
• Avoid exacerbating activities
• Conserve energy
• Limit people in room
• Reduce room temperature, maintain humidity
• Open window and allow to see outside
• Avoid irritants, e. g. smoke
• Relaxation therapy

50. Specific Treatments
• PE – anticoagulation
• Pleural effusion – pleural aspiration +/- pleurodesis
• Pain – analgesia
• Anaemia – transfusion
• Depression/panic attack – antidepressants,
benzodiazepines, non-pharmacological approaches
• Heart failure – diuretics, fluid restriction (oxygen)

51. Specific Treatments
• Infection – antibiotics, physiotherapy
• Airway obstruction
– Large – stenting, XRT, brachytherapy
(endobronchial), laser, corticosteroids
(dexamethasone, prednisolone)
– Small – bronchodilators (nebs), corticosteroids
• SVCO – corticosteroids, stenting, chemo/XRT
• Lymphangitis – corticosteroids, chemotherapy

52. Pharmacological Measures
to Control Dyspnoea
• Oxygen
• Opioids
• Benzodiazepines

53. • Opioids
– Reduce ventilatory response to hypercapnia (↑CO2), hypoxia,
and exercise
– Benefit is seen with oral or parenteral doses that do not cause
respiratory depression
– No evidence for the use of opioids by nebulised route
– CSCI morphine may suit some patients better, avoiding peaks
and troughs of oral medications
– Titration is required, as with pain management
– Main side effects: nausea and vomiting, constipation
General Management: Pharmacological approaches

54. • Opioids (PCF4)
– Opioid-naïve patients:
• 2.5-5mg PO PRN
• If ≥ 2 doses/24 hours are needed, then prescribe regularly
– Relatively small doses may suffice e.g. 20-60mg/24 hours
– Patients already on opioids for pain:
• dose equivalent of 100% or greater of 4 hour breakthrough
if dyspnoea severe
• 50-100% of breakthrough if moderate dyspnoea
• 25-50% of breakthrough if mild dyspnoea
General Management: Pharmacological approaches

55. • Opioids (PCF4): use in non-cancer patients
– Lower dose is advocate in patients with COPD
• e.g. 1mg bd, increased to 1mg -2.5mg 4 hourly over one
week
• Then increase by 25% per week
• Consider switch to a MR formulation when stable
General Management: Pharmacological approaches
Caution with renal and hepatic impairment, elderly or frail patients

56. Opioids in Dyspnoea
• Safe and effective
• Diminishes the
sensation of being short
of breath
• RCTs have confirmed
the usefulness and
safety of opioids in
patients with advanced
cancer, ALS and end-
stage heart and lung
diseases

57. • Benzodiazepines
– No evidence for breathlessness but may be used for
anxiety
– Panic Attacks – education and reassurance regarding fear
of suffocation, teaching breathing techniques, CBT, +/-
benzodiazepines
• Lorazepam 0.5mg SL PRN
• Diazepam 2mg-5mg b.d. recommended in Palliative
Adult Network Guidelines
• Midazolam CSCI in terminal care
General Management: Pharmacological approaches

58. • Oxygen
– Both air and oxygen reduce breathlessness in patients with
cancer
– Can be helpful even in absence of hypoxia – although trial has
shown no benefit of oxygen over room air in these patients
– Considerable costs – financial, patient and family anxiety,
safety issues, practical issues
– Always remember special considerations in patients with
COPD and MND
– Trial fan first
General Management: Pharmacological approaches

59. General Management: Pharmacological approaches
• Bronchodilators
– Even in absence of wheeze there may be element of
reversible bronchoconstriction
– Trial of Salbutamol 2.5-5mg QID Neb/ 2 puffs via spacer
QID +/- Ipratropium 250-500 mcg QID Neb

60. • Corticosteroids—for bronchospasm or
reduced airway calibre due to tumour
– Lymphangitis carcinomatosis,
reduction of peri-tumour oedema in
patients with multiple lung mets
– Benefit should be apparent within
days
– Dexamethasone 4mg-8mg mane for
1/52 trial and if no improvement stop
– Monitor blood sugars
Pharmacological approaches

61. Panic attacks-patient advice
• Stay calm
• Purse your lips
• Relax shoulders, back, neck, arms
• Concentrate on breathing out slowly

62. Severe Dyspnoea in Last Hours of Life
• Traumatic for patient, family and staff
• Needs active management
• Parenteral medications essential ie SC or CSCI
• Focus on controlling dyspnoea rather than the
dose of opioids and other medications
• Call for help if you have not managed this before

63. Severe Dyspnoea in Last Hours of Life
• Opioid naïve
– 2.5 – 5 mg morphine IV/SC stat then reassess
• Opioid tolerant
– 25% to 100% increase in dose IV/SC stat
• Add midazolam and titrate dose if above ineffective
• Intractable dyspnoea – seek advice from Specialist
Palliative Care

64. NAUSEA AND VOMITING

65. Content
• Causes of nausea and vomiting in palliative
care
• Pathophysiology of N/V
• Neuroanatomy and transmitters involved
• Management of N/V
• Drug options
• Summary table

66. Common Causes of Nausea and
Vomiting in Palliative Care
Cause often has multi-factorial etiology:
• Constipation
• Drugs
– Opioids
– Non-steroidal anti-inflammatories (NSAIDs)
– Selective serotonin reuptake inhibitors
• Reduced gastro-intestinal motility
– Drugs (opioids, tricyclic antidepressants)
– Autonomic neuropathy
• Metastatic bowel disease / obstruction

67. Common Causes of Nausea and
Vomiting in Palliative Care (continued)
• Anorexia-cachexia syndrome
• Metabolic causes:
– Hyper Ca++
– Uraemia
– Hypo Na+
• Increased intracranial pressure
• Oral candidiasis
• Anxiety
• May be aggravated by uncontrolled pain

68. The vomiting reflex - 1

69. Direction of muscular
contractions
Flow of gastric contents
The vomiting reflex - 2

70. Anatomical representation of parts of brain involved
with nausea and vomiting
Cerebellum
4th ventricle
Vomiting Centre
Area postrema
and CTZ Nucleus of the
solitary tract

71. Factors influencing nausea and vomiting
Vomiting Centre
(medulla)
Stomach
Small intestine
Higher cortical
centres
Chemoreceptor
Trigger Zone
(area prostrema,
4th ventricle)
Labyrinths
Vomiting Reflex
Neuronal pathways

72. Receptors involved

74. Factors influencing nausea and vomiting
Vomiting Centre
(medulla)
Stomach
Small intestine
Higher cortical
centres
Chemoreceptor
Trigger Zone
(area prostrema,
4th ventricle)
Memory, fear, anticipation
Surgery
Surgery
Labyrinths
Anaesthetics
Vomiting Reflex
Neuronal pathways
Factors which can
cause nausea & vomiting
Chemotherapy
Chemotherapy
Radiotherapy
Opioids

75. Drug treatment of nausea and vomiting
Vomiting Centre
(medulla)
Stomach
Small intestine
Higher cortical
centres
Chemoreceptor
Trigger Zone
(area prostrema,
4th ventricle)
Memory, fear, anticipationSensory input (pain, smell, sight)
Surgery
Surgery
Labyrinths
Anaesthetics
Vomiting Reflex
Neuronal pathways
Factors which can
cause nausea & vomiting
Chemotherapy
Chemotherapy
Radiotherapy
Opioids
Sites of action of drugs
5HT3
antagonists
Sphincter modulators
Histamine antagonists
Muscarinic antagonists
Gastroprokinetic
agents
Benzodiazepines
Histamine antagonists
Muscarinic antagonists
Dopamine antagonists
Cannabinoids

76. Common causes of vomiting
• GI causes
• Drugs
• Metabolic
• Toxic
• Brain metastases
• Psychosomatic factors
• Pain
• Vestibular
• Obstruction
• dysMotility
• Infection, inflammation
• Toxins

77. Clinical pictures/ Fairmile Guidelines on
management of Nausea and vomiting
Bentley, Boyd Pall Med 2001
• Chemical / Metabolic
– Persistent, little relief vomiting
• Gastric stasis/ gastric outlet obstruction
– Intermittent, relief from vomiting
• Regurgitation
– Dysphagia, little nausea
• Bowel obstruction
– Nausea, colic, faeculent vomiting
• Cranial disease / treatment
• Movement related
• Unclear, multiple

78. Nausea & Vomiting
Management principles
• Reverse cause if possible
• Non drug measures
• Continuous problem requires continuous antiemetic
therapy
• If vomiting, consider route- may need syringe driver /
iv route
• PRN medication
• Reassessment

79. Nasogastric Suction versus
Venting Gastrostomy
• Only justified in carefully
defined circumstances
• Intrusive and potentially
distressing
• Complications
• If decompression needed
for prolonged periods.
• C/I uncorrectable coagulopathy
• Unfavourable anatomy
• Massive ascites
• Gastric cancer
• Active gastritis/ peptic ulcer
• Gastric varices

80. Self-expanding metal stent
Self-expanding metal stent in-situ

81. Management of Nausea
• Attempt to identify the underlying cause(s)
• Attempt to correct the underlying cause(s) if possible
and if appropriate
• Treat the symptoms
– Anti-emetics selected according to the inferred
underlying mechanisms
• Prevent nausea
– Employ a regular anti-emetic regimen if nausea is
prolonged
– Prevent constipation
• If one agent not completely effective, review and add
another or replace with another

82. Anti-Emetics
• Anti-dopamine agents
– Metoclopramide
– Domperidone
– Haloperidol
– (Olanzapine)
• Anticholinergic
– Hyoscine Hydrobromide
• Anticholinergic and
antidopaminergic
– Levomepromazine
• 5HT3 antagonists
•Ondansetron
•Antihistamines
•Cyclizine

83. Anti-Emetics
Pro-motility and anti-dopamine agents
• Metoclopramide 10-20 mg qid po/sc/pr
– Extrapyramidal side effects may occur
– Upper GI pro-motility
• Domperidone 10-20 mg qid po
– Only po formulation
– Less likely to cause extra-pyramidal side effects
– Upper GI pro-motility
• Extra-pyramidal side effects and akathisia are
relatively uncommon, but monitor for these.

84. Anti-Emetics
• Antidopamine agents
– Haloperidol 0.5 - 2 mg po/sc (max 5mg per 24 hours)
– Levomepromazine 5 - 10 mg po/sc od-tid
– Useful in the context of malignant bowel obstruction
 Steroids
– Dexamethasone 4-8 mg po/sc, od-bid
• 5 HT3 antagonists
– Useful second and third line agents
– e.g. Ondansetron (4mg stat up to max 16mg/24 hrs)

85. Cause Drug Oral dose Syringe driver (24
hrs)
Gastric stasis Prokinetic agent eg
metoclopramide
10-20mg tds 40 - 80mg
Renal failure Haloperidol (anti-DA)
Cyclizine
1-3mg od
50mg tds
1 - 3mg (may accumulate)
150mg
Chemotherapy Ondansetron
(5HT-3 antagonists)
Dexamethasone
8mg bd
4mg bd
8 - 16mg
Unclear or multiple causes Cyclizine (anti-cholinergic)
OR
Levomepromazine (broad
spectrum)
50mg tds
6-12.5mg bd
100 -150mg
5 - 25mg
Intestinal obstruction Cyclizine (anti-cholinergic)
±
Haloperidol (anti-
dopamine)
150mg
3mg

86. Indications for using syringe-drivers
• Intractable vomiting
• Severe dysphagia
• Unable to swallow orals
• Reduced level of
consciousness
• Poor alimentary
absorption
• Poor compliance

87. Fatigue and quality of life

88. Fatigue
“ACUTE”
• Short duration.
• Rapid onset.
• Resolves quickly.
• Identifiable cause.
• Expected or
anticipated.
• Serves protective
function.

89. Fatigue
“CHRONIC”
• Longer duration.
• Gradual,cumulative onset.
• Does not resolve quickly.
• Multiple causes, not easily identified.
• Often no relation to activity.
• Maladaptive,no protective function. Major
impact on quality of life.

90. Fatigue Assessment
• Fatigue pattern.
• Type and degree of disease.
• Treatment history.
• Current medications.
• Sleep and/or rest patterns.
• Nutrition intake and any appetite or weight
changes.

91. Domains in Quality of Life
Macmillan & Mahon
physical/
functional
social
psychological/
spiritualeconomic
PAIN

92. B
A
Time
Hopes,
ambitions
Present
reality
Modified
expectations
Improved
circumstances
Gap reflects QOL
“Calman Gap”

93. Key points

94. Venous Access Devices
• Choice of device depends on type of therapy, duration, frequency, volume and
location of delivery. Vascular anatomy and patient choice important too.
– Peripheral
– Midline (rare in oncology, tip around axilla)
– Central
• Peripheral catheters:
– Most common
– Short term therapy
– Gauge: 24 the smallest, want to minimise discomfort or risk of damage. yellow.
– Site: above wrist, below elbow. 2 bones act as a splint.
– Care and maintenance: infection control
– Extravasation: inadvertent release of drug into surrounding tissue potentially causing
necrosis or tissue damage.
– Smallest cannula in biggest possible vein to reduce phlebitis
• Midline Catheters
– Does not extend beyond the axillary vein
– Short term therapy 2-4weeks
– No vesicant drugs: potential to cause necrosis if extravasated. Can lead to amputation
– No high pH drugs
– No high osmolarity

95. Venous Access Devices
• Central Catheters
– TIP LOCATED IN SUPERIOR VENA CAVA
– Non-tunnelled: neck, ICU
– Peripherally Inserted Central Catheter: PICC
– Tunnelled: Hickman line
– Implantable port
– 50-60cms long, 2-12.5 Francs
– Single/double/triple lumen configurations
– Open end/closed valve system
• PICC 4-5French. 1200/year.
– Non-surgical procedure, put in by nurses, takes 2hours
– Blue can have single or double lumen. Purple is suitable for power infusions
– Topical anaesthetic, access above antecubital, cephalic or median vein
– Basilic largest and straightest route leading to SVC, catheter advanced to tip in SVC
– Confirmed radiologically
– Cannula generally enough but: poor venous access, some chemo requires bigger lumen
• Tunnelled: Hickman. 11 French.
– Cuffed catheter, in angiosuite or theatre. Surgical procedure
– Local anaesthetic, access via subclavian/jugular vein with subcutaneous tunnel to exit
– Dacron cuff, sutured in: 7 days neck, 21 chest wall. Confirmed by fluoroscopy.
– Dacron cuff causes granulation tissue to develop which holds port in place
– Needed for pts with double mastectomy due to lymphoedema and vein preservation.
– Haematology patients: thicker bore so can take thicker solution. 11 French.

96. Venous Access Devices• Implantable port
– Surgical procedure requiring general anaesthetic/local
– 2 components: port and catheter
– Catheter tunnelled under skin, access through subclavian vein
– Port sits subcut on chest wall
– Anchored with sutures, overlying skin surgically closed
– Confirmed by fluoroscopy
– Access by Huber needle – locate port chamber and put Huber needle on.
• Potential Complications:
– Air embolism
– Pneumothorax/haemothorax
– Mechanical phlebitis
– Infection: lowest risk with port.
– Occlusion: use urokinase to unblock
– Thrombosis: erythema of affected limb, discomfort/pyrexia, pain, swelling and
distension, infusion difficulties. Rx: correct flushing, anticoagulate. Catheter removal
LAST RESORT
– Migration/malposition: more with RCC as no suture etc
– Extravasation
– Catheter fracture

97. Palliative Care
• Most common symptoms:
– Pain 84%
– Nausea and vomiting 51%
– Dyspnoea 47%
– Constipation 47%
• How you know you are near the end:
– rapidly increasing weakness or fatigue
– Bed bound
– Decreasing intake of food and fluids
– Difficulty swallowing
– Decreasing Level of consciousness
• Check its not another cause which can be treated e.g. infection/toxicity
• Death rattle: phlegm in throat that cant shift as cilia paralysed giving pt a
rattle which distresses family – scopolamine (hyoscine hydrobromide) or
glycopyrolate

98. Palliative Care
• Pain Management
– Types of suffering: pain, physical symptoms, psychological, cultural, spiritual, social
and financial
– Pain: unpleasant sensory and emotional experience associated with actual or
potential tissue damage
– Acute pain generally begins suddenly, is temporary and subsides itself/after treatment
of the cause
– Chronic pain persists or recurs for prolonged, indefinite periods of time: change in
pain pathway so pain persists despite healing.
– Inflammatory response causes acute pain
– Pain assessment: measure regularly, scale of 1-10 or smiley faces. Cause of pain
should be identified and treated.
– Investigations may be useful: Bone scans or CT
– Types of pain in cancer
• Nociceptive pain: somatic or visceral
• Neuropathic pain: central or peripheral
• Visceral pain
• Bony pain
• Referred pain
• Breakthrough pain

99. Breathlessness
• Dyspnoea:
– Subjective feeling: awareness of being short of breath
– Devastating symptom in advanced cancer, ALS, end-stage lung disease and heart
disease: occurs in 60% of these patients
– Complex symptom
– Feel short of breath  panic  processed in amygdala and hippocampus, adrenaline
released  hyperventilation  blow off CO2  respiratory alkalosis  free calcium
binds to albumin  hypocalcaemic  tetany  cannot physically breathe
– Causes: lung tumours, lung collapse, effusion, TB, lymphangitis carcinomatosis, SVC
obstruction, chest wall pain, muscle weakness, ascites from abdominal tumour pushing
against diaphragm
– Causes treatment related: surgery e.g. lobectomy, radiation induced fibrosis, chemo:
pneumonitis, interstitial fibrosis, drugs – NSAIDs
– Causes – debility: infection, anaemia, fatigue, muscle weakness, PE
– Others: COPD, asthma, arrythmias, pneumothorax, acidosis, anxiety/distress
• Assessment
– Good history and examination to find cause if possible
– Not directly correlated to O2 sats
– Pattern: intermittent/chronic, continuous, short acute episodes, better/worse, triggers

100. • Management:
– Pleural effusion: thoracocentesis
– Large airway obstruction: stenting, radiotherapy
– Pneumonia: Abx
– Lymphangitis carcinomatosis: high dose steroids
– Anaemia: transfusion trial
– CHF/COPD: optimise treatments
– ALS: non-invasive ventilation
• General Principles:
– Reassure patient and explain what is happening
– Try distraction/relaxation techniques
– Change their expectations of what they can manage
• Non pharmacological
– Use a fan/open a window, less people in the room
– Position: lean forward with head up..
– Avoid exacerbating factors, conserve energy
– Avoid irritants e.g. smoke and encourage relaxation therapy
• Drugs
– Oxygen – caution type II respiratory failure
– Benzodiazepines: calm patient
– Opioids: diminished sensation of SOB, start small on orals. Especially in last hours.
Breathlessness

101. N&V
• Causes:
– Constipation
– Drugs: opioids, NSAIDs, SSRIs (SIADH causing low Na also caused by several cancers)
– Reduced GI motility: due to drugs – opioids and TCAs, autonomic neuropathy
– MET bowel disease/obstruction
– Anorexia-cachexia syndrome
– Metabolic causes: hypercalcaemia, uraemia, hyponatraemia (lung tumours ADH)
– Raised ICP
– Oral candidiasis
– Anxiety, pain
• Management
– Try identify and treat underlying cause
– Treat the symptoms by selecting anti-emetic that works on affected pathway
– Prevent nausea by giving regular anti-emetic as opposed to PRN
– Review – if one drug not working, add another/change
• Anti-dopaminergic – good for malignant bowel obstruction
– metoclopramide: may get EPSEs, upper GI pro-motility
– Domperidone: less EPSEs
– Haloperidol: raised QT interval and EPSE
– olanzapine

102. N&V
• Anticholinergic
– Hyoscine hydrobromide
• Anticholinergic and anti-dopaminergic
– Levomepromazine
• Serotonin antagonists – 2/3 line.
– Ondansetron: good for chemo/radiotherapy induced N&V. prolonged QT syndrome
• Antihistamines
– Cyclizine
• Steroids: increased appetite
– dexamethasone