20: TERMINAL CARE

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CHAPTER 20 TERMINAL CARE

Breaking bad news
Pain
Controlled drugs
Vomiting
Anorexia
Anxiety
Constipation
Cough
Depression
Dyspnoea
Death
Bereavement

BREAKING BAD NEWS

Telling patients or their relatives about a terminal condition is never an easy job, but the GP, with a prior knowledge of the patient and family, is often the best person to break the bad news.

Before seeing the patient

Get all the facts beforehand, allow plenty of time and ensure there will be no interruptions.

Facts often needed include:

• prognosis
• symptoms to be expected
• treatment and side-effects.

What to say and how to say it

• Tell the truth.
• Recap on knowledge already gained, e.g. ‘What did they tell you in hospital?’
• Stick to the terms used by the patient, e.g. ‘growth’, ‘tumour’.
• Give factual knowledge in simple terms.
• Allow the patient to be defensive.
• Do not give more information than the patient wants.
• Try to discover the patient’s fears.
• Give positive aspects, e.g. professional support, effective analgesia.

Follow-up.

Make a further appointment to see the patient, who may feel isolated. Offer telephone access in the meantime. Suggest district nurse involvement.

Tip

The patient may come to terms with the realities of the illness only after several discussions along the above lines.

Administration

All patients with less than 6 months’ life expectancy are eligible for Attendance Allowance, irrespective of their need for care. Apply with form DS1500 (available from Social Services). The reverse side of the form is for the GP to claim a fee for this service from the Benefits Agency.

PAIN

The thought of being in pain due to a terminal illness frightens many patients. This fear is sometimes not stated.

Ask patients if they have pain, rather than waiting for them to volunteer it.

Tip

Pain and anxiety reinforce one another. Anxiolytics can help control pain.

Management of pain relief in palliative care

• Diagnose the cause of pain if possible, e.g. tumour mass, bone metastases, nerve compression, abdominal distension.
• Think of non-drug methods of pain relief, e.g. radiotherapy, surgery, relief of constipation, draining ascites, psychosocial support.
• Do not forget to treat anxiety as an adjunct to pain relief (see p. 294).
• Always bear in mind the potential side-effects of drugs (see constipation, p. 323, and vomiting, p. 320).

Tip

Using combinations of analgesics early, rather than increasing the dose of one drug, is often useful. The resulting effect is often greater than the sum of the individual drugs.

Examples of useful analgesics

(See controlled drugs, p. 319.)

Mild analgesics

• Paracetamol 500 mg, 1–2 tablets 4–6-hourly prn.
• Ibuprofen 400 mg, 1 tablet tds prn.

Moderate analgesics

• Co-codamol 30/500, 1–2 tablets 4–6-hourly (max = 8 tabs/24 hours) prn.
• Dihydrocodeine 30 mg, 1–2 tablets 4–6-hourly prn.
• Diclofenac 50 mg tds prn.

Strong analgesics

• Morphine sulphate elixir 10 mg/5 ml (Oramorph).
• Morphine sulphate solution 20 mg/ml.
• Morphine sulphate Continus tablets (MST) 5, 10, 30, 60, 100 and 200 mg tablets.
• Morphine sulphate suppositories 10, 20 and 30 mg.
• Diamorphine injection 5, 10, 30, 100 and 500 mg.

How to achieve the correct dose of opiate

• Once it becomes apparent that mild and moderate analgesics are inadequate, substitute oral morphine 5 mg 4-hourly. Regular 4-hourly dosage is preferable, as the aim is total analgesia, without breakthrough pain.
• Increase the dose if necessary by titrating against the pain and giving more morphine, but at the same 4-hourly intervals.

Converting oral morphine solution to MST

• Once satisfactory pain control has been achieved, divide the total 24-hourly dose of morphine by 2 and give this dose as MST at 12-hour intervals, e.g. 10 ml of morphine sulphate elixir every 4 hours at 10 mg/5 ml equates to 60 mg bd of MST.
• As time goes on and the patient develops a tolerance to opiates, the dose of morphine will need to be increased. Use additional morphine sulphate elixir as a top-up initially, and when pain control is again achieved, divide the total 24-hourly dose by 2 and convert to the new dose of MST.
• Giving an NSAID such as diclofenac tablets 50 mg tds as well as the morphine can improve pain control, avoiding the side-effects of increased doses of opiates.

Tip

Morphine sulphate suppositories are useful if a patient whose pain is well controlled on oral medication starts vomiting (unless the vomiting is due to too high a dose of morphine).

Converting oral morphine to diamorphine

• Diamorphine injections are useful for short-term relief of severe pain in e.g. MI. In terminal care, however, diamorphine can be given by subcutaneous infusion via a syringe driver. For practical purposes, injected diamorphine is about three times as powerful as oral morphine on a dose-for-dose basis. For example, the patient requiring MST 90 mg bd would need 60 mg diamorphine over 24 hours.
• Common side-effects of opiates include:

– constipation
– nausea and vomiting, particularly in the initial stages of treatment
– drowsiness
– anorexia
– confusion.

Specific types of pain

Gastrointestinal pain

• Gastric distension pain. Try an antacid with simeticone (e.g. Asilone) or domperidone, 10 mg tds.
• Bowel colic. Try loperimide 2–4 mg qds or hyoscine hydrobromide sublingually 300 μg tds.

Nerve pain,

e.g. due to compression by a tumour mass or lymphadenopathy. Dexamethasone tablets 4–8 mg bd may reduce oedema around a tumour in the short term. Radiotherapy often provides relief for longer.

Muscle spasm.

This may be helped by the muscle relaxant baclofen 5–10 mg tds. Alternatively, try diazepam 5–10 mg daily.

Bone pain,

e.g. due to metastases. Opiate analgesics are the mainstay of treatment (see above). Radiotherapy and NSAIDs provide useful additional relief.

CONTROLLED DRUGS

For choices of drugs and dosages, see pain, p. 317.

Legal aspects

For prescribing opiates on the prescription form FP10 a few simple rules have to be followed:

• The form, strength and dose of the drug must be stated, e.g. morphine sulphate elixir 10 mg/5 ml, 10 mg 4-hourly.
• The total amount of drug must be stated in words and figures, e.g. one hundred millilitres 100 ml.

For carrying controlled drugs in the black bag there are a few legal requirements:

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