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:

• Keep a bound ledger to record the acquisition and administration of all controlled drugs. Use a different page for each form of drug. Record the amount, form and concentration of each drug and the dates acquired and used. Any difference between acquired and used drugs should equal what is left in the bag.
• If the black bag is left in the car it should be locked and the car should also be locked. Alternatively, controlled drugs can be kept in a separate locked container if left in a locked car.
• If stock goes out of date it can either be returned to the chemist or destroyed. Officially, the destroying of controlled drugs should be witnessed by an appointed official of the PCT.

Ethical considerations

• In terminal care, the fear of addiction to opiates should not deter the doctor from adequately prescribing for pain relief.
• Addiction is unlikely to occur if the dose of opiate is adequate and given regularly.
• In the dying patient, pain and distress can prolong life by their stimulating effect on respiratory rate and arousal. Opiates relieve this distress and can allow patients to die peacefully, if somewhat earlier than they would otherwise have done. This should not be considered a form of euthanasia. The dose of an opiate required to suppress the respiratory centre is much greater than that needed for pain relief.

VOMITING

Causes of vomiting in the terminally ill patient

• Drug side-effects, particularly chemotherapy drugs and opiates.
• Intestinal obstruction.
• Pain.
• Raised intracranial pressure, e.g. from cerebral metastases.
• Uraemia.
• Anxiety.
• Hypercalcaemia.

Nausea and vomiting are common symptoms in terminal care.

Diagnosis

History.

Ask about:

• pain control
• drug regimen
• bowel/stoma function
• headache
• micturition.

Examination.

Look for:

• abdominal signs of obstruction
• papilloedema if raised intracranial pressure is suspected.

Investigations

• C&Es
• calcium.

Tip

Treat the underlying cause if possible. Hospital/hospice admission is indicated if the cause of vomiting remains undiagnosed.

Management

Reassure patients that their nausea can be treated.

Prescribing.

(e.g. for nausea associated with opiate analgesics):

• Prochlorperazine:

– oral 5–10 mg tds
– buccal 3–6 mg bd
– suppository 5 and 25 mg
– injection 12.5 mg.

• Metoclopramide: tablets and injection 10 mg tds.
• Domperidone:

– tablets 10–20 mg 4–8-hourly
– suppository 30–60 mg tds.

• Cyclizine: injection 50 mg tds. Cyclizine is useful when mixed with diamorphine in a syringe-driver as it can be given by subcutaneous infusion.

Side-effects

• Prochlorperazine and metoclopramide cause drowsiness and can cause acute dystonic reactions in younger patients.
• Domperidone is less sedating. Dystonia has been reported but is uncommon.
• Cyclizine can cause drowsiness, dry mouth and blurred vision.

Haematemesis.

This may be the final event in the course of a terminal illness.

Diamorphine by im injection can help relieve the acute distress to the patient.

A red blanket on the bed helps to disguise the amount of blood being lost.

ANOREXIA

Anorexia is an inevitable feature of terminal care, as the appetite wanes and eating becomes too much of an effort.

Tip

Anorexia is very common in the final few days of life and is often of more concern to the carers than to the patient. It may require no treatment, although attempting to improve the appetite may improve morale.

Management

• Exclude treatable causes:

– drug side-effects
– nausea
– depression
– abdominal obstruction
– sore mouth, e.g. due to thrush.

• Simple measures:

– give small helpings of food
– use a small plate
– suggest alcohol as an aperitif.

• Drug treatment:

– prednisolone E/C tablets 5 mg tds
– alternatively, dexamethasone 2–4 mg daily.

Tip

It is rarely justifiable to use steroids simply to boost appetite, although steroids prescribed for other indications will improve overall well-being, including the appetite.

ANXIETY

Anxiety in the terminally ill may manifest itself as restlessness, confusion, agitation, depression or anger.

Diagnosis

History.

Ask about:

• symptoms common to terminal care, e.g. pain, vomiting, dyspnoea, constipation, anorexia
• psychosocial problems, e.g. distressed relatives, fear of dying or suffering, fear of hospitalisation
• free-floating anxiety; also pre-existing anxiety states
• drug side-effects.

Management

• Treat the underlying cause if possible.
• Give regular support and reassurance.
• Recognise anxiety and depression.
• Involve the district nurse, Marie Curie nurse, Macmillan nurse and hospice or social worker, if appropriate, at an early stage.

Prescribing

• Antidepressants, e.g. citalopram 20 mg daily.
• Anxiolytics, e.g. chlorpromazine tablets or syrup 25 mg tds, increasing by 25 mg daily at weekly intervals until control is achieved.

Alternatively, use haloperidol 1–3 mg tds, which is less sedating.

For short-term use in acute anxiety, use diazepam 2 or 5 mg up to tds.

Tip

Midazolam 40 mg can be given via a syringe-driver and can be mixed with diamorphine in the same syringe.

CONSTIPATION

Aim to prevent constipation in terminal care by prescribing laxatives in conjunction with opiate analgesics.

Causes of constipation in the terminally ill include:

• opiate analgesics
• decreased mobility
• decreased fluid intake
• anorexia
• obstruction, e.g. due to tumour.

Tip

The overloaded colon may present with overflow diarrhoea. In this case liquefied stool bypasses a constipated segment of bowel. This possibility is worth bearing in mind when a patient on morphine presents with diarrhoea.

Management

(See also p. 124.)

• Always prescribe a laxative when giving opiate analgesics, e.g. the faecal softener and peristaltic stimulant co-danthramer 5–10 ml bd.
• Exclude obstruction (absolute constipation, vomiting and distension, abdominal pain).
• If constipation occurs, consider an osmotic laxative e.g. lactulose 10 ml bd and a stimulant laxative, e.g. senna 2 tablets nocte.
• Stronger treatments may be necessary if the above measures fail, e.g. Movicol 1–3 sachets daily in divided doses or bisacodyl suppositories 10 mg (work within 20–30 minutes; may cause griping abdominal pains). Alternatively, glycerol suppositories, docusate sodium or phosphate enemas may be useful.

COUGH

Cough is a common symptom in carcinoma of the bronchus.

Tip

Some consequences of cough include insomnia and breathlessness. Carers may be disturbed at night.

Management

• Steam inhalations.
• Pholcodine linctus 10 ml 4-hourly.
• Morphine linctus 5 mg 4-hourly, increased until effective.

DEPRESSION

All terminally ill patients manifest depression at some stage of their illness. For depression in general, see p. 292.

Features of depression peculiar to terminal illness

• Ask about symptoms and look for signs of depression. The patient or carers may not volunteer these, leading to delayed diagnosis.
• Carer stress and depression are also common and should be sought.
• Features of depression may be masked by drugs used in terminal care, e.g. opiates and phenothiazines.
• Drug side-effects and interactions may complicate treatment, e.g. tricyclics and morphine both exacerbate constipation.
• District nurses, Macmillan nurses and Marie Curie nurses are an invaluable resource in the management of depression, both for identifying the condition and for supporting patients.

The recently bereaved are at increased risk of suicide.

• The regular, close observation of the terminally ill patient by the GP should provide adequate opportunity for the detection and treatment of depression.

DYSPNOEA

Respiratory distress is common in terminal emphysema and carcinoma of the bronchus and may become a problem long before the patient is dying. Cheyne–Stokes breathing, on the other hand, is an almost universal feature of the last few hours of life, in anyone dying of malignant disease.

Management

Management of respiratory distress

• Exclude chest infection, pleural effusion and bronchospasm.
• Relieve the distress of dyspnoea with oral morphine 5 mg 4-hourly, increasing as necessary.
• Alternatively, use diazepam 5–10 mg daily.

Management of excessive respiratory secretions.

These are the cause of the ‘death rattle’ heard during the last few hours of the dying patient’s life.

Give hyoscine or atropine injection (sc or im) 600 μg tds. Hyoscine hydrobromide may be given in a subcutaneous infusion 0.6–2.4 mg/24 hours, and may be mixed with diamorphine.

DEATH

Most GPs will be involved in confirming or certifying a death approximately every 2 months, more frequently in the winter.

Talking to relatives

See p. 327.

Confirming death

When called to attend a patient who has died, the first task is usually to confirm death. Examine for:

• carotid pulse
• heart sounds
• general appearance
• fixed, dilated pupils.

Tip

If the death occurs in the middle of the night, but was expected by the relatives or nursing-home staff, the examination to confirm death can be performed by a nurse or undertaker. The GP will still need to see the body of the deceased if a cremation certificate is required, but this can be done in normal hours.

Who to inform

At the time of confirming death it may only be necessary to inform those present – usually the relatives, especially if the death was expected.

Other people may need informing under the following circumstances:

• Relatives: if requested by those present at death.
• Undertaker: if requested by relatives.
• Coroner, if:

– the death is sudden or unexplained
– a doctor has not attended within the preceding 14 days
– the death may be due to industrial disease, or related to the deceased’s employment
– the death was violent, unnatural or suspicious
– the death may be due to an accident
– the death may be due to self-neglect or neglect by others
– the death may be due to an abortion
– the death occurred during an operation or before recovery from the effects of an anaesthetic
– the death may be a suicide
– the death occurred during or shortly after detention in police or prison custody

• Out-of-hours the coroner may not be available, in which case call the police.

Other people may need informing, but this can be done from the surgery during the next working day if necessary:

• a doctor from another practice if a Cremation Form Part B is required
• the patient’s usual doctor
• primary healthcare team members, if involved
• practice receptionist, to de-register the patient and cancel appointment reminders.

Administration

Forms

Death certificate.

The death certificate can be completed if the cause of death is known and the patient has been seen within the preceding 14 days by the doctor. If more than 14 days have elapsed, discuss the case with the coroner, who will probably ‘pass’ it if the cause of death is known. If in doubt, phone the coroner. Indicate on the back of the death certificate that the coroner has been informed.

The death certificate, if completed, can be given to the relatives, who use it to register the death at the Registrar’s Office. If the death is made a coroner’s case, the coroner issues the death certificate.

Cremation form.

The cremation certificate can be filled in only by doctors who have seen the dead body. Two doctors are required. The Part B doctor must have been fully registered for 5 years or more, must be from a different practice and must have discussed the death with the Part A doctor. The doctor completing Part B must also discuss the circumstances of the patient’s death with either a relative or a member of the nursing team who was involved in the patient’s final illness. The cremation form should be given to the undertaker.

Fees.

A fee is paid by the undertaker for completing Part A or Part B of a cremation certificate. No fee can be claimed for completing a death certificate.

BEREAVEMENT

See also breaking bad news, p. 316.

Tip

Anniversaries can rekindle various stages of bereavement.

Bereavement can be experienced following a loss other than a death, e.g. loss of marriage, job, pregnancy, limb.

The stages of bereavement

1. Shock.
2. Denial.
3. Anger.
4. Acceptance.

As a rule of thumb, the first two stages should last no longer than a few days. Any significant lengthening of these stages should alert the GP to the possibility of an abnormal bereavement. Stages three and four can take longer, sometimes months, to complete.

Management

Most patients appreciate continued support at this time. Encouraging patients to talk about their loss helps the grieving process.

Inform the patient about support groups, e.g. CRUSE (see p. 356).

Enlist the help of others. The district nurse, social worker or a bereavement counsellor (e.g. from the hospice) may be useful.

There is an increased suicide risk in the recently bereaved. Involve the psychiatric team early in suspected abnormal grief or severe depression.

Administration

Quality and Outcomes Framework for Palliative Care and Cancer

• Hold multidisciplinary case review meetings at least 3-monthly where all patients on the palliative care register are discussed.
• Review the care of each new cancer patient within 6 months of confirmation of diagnosis.

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