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Palliative care emergencies 1: diagnosis

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Author

Megan Rosser, MSc, PGCE, BSc, RGN, DN Cert, is nurse lecturer, School of Health Science, University of Swansea

Article

The most common conditions that constitute a palliative care emergency are spinal cord compression, superior vena cava obstruction (SVCO) and hypercalcaemia.

These conditions, which are generally the consequence of advancing malignant disease, can be controlled for some months but need to be regarded as emergencies in order to avoid severe permanent damage and to maintain the patient’s quality of life for as long as possible.

It is therefore important that nurses can recognise the early signs of these conditions in order to liaise with the multiprofessional team to ensure prompt treatment.

Spinal cord compression

Spinal cord compression is, as it suggests, compression of the spinal cord that causes progressive and irreversible neurological damage (Watson, 2006) and is therefore a true emergency.

The aim of swift, accurate diagnosis and treatment is to maintain or restore motor function in patients who otherwise face the rest of their life with diminished mobility, continence and independence.

The outcomes of treatment are related to patients’ level of function at time of presentation: 70-80% of patients walking at presentation will continue to walk following treatment while only 5-10% of those unable to walk at presentation will regain that function (Cervantes and Chirivella, 2004). Patients who are described as ‘going off their legs’ should set alarm bells ringing in nurses’ minds and a full neurological assessment should be requested from the GP or medical team.

Nurses are vital in observing patients at risk of compression and reporting their findings to the medical team.

Spinal cord compression occurs in 5-10% of all patients with cancer and is most common in patients living with breast, lung or prostatic cancers (Downing, 2001). It is usually caused by metastatic spread to the vertebrae (Salt, 2003) and therefore occurs in patients with advancing disease.

Signs and symptoms of spinal cord compression

Pain is the primary presenting symptom of spinal cord compression and may precede other symptoms by months. Therefore patients with a history of cancer who present with back pain should always be presumed to have spinal cord compression until proven otherwise (Watson, 2006). This does not always occur because back pain is a common experience for many people with or without a cancer diagnosis and early symptoms are varied and sometimes hard to detect. Patients may delay seeing a doctor as they think back pain is caused by something less sinister such as muscle strain; equally, doctors may misdiagnose the symptoms as joint degeneration or arthritis (Downing, 2001).

It is therefore important to note that some aspects of the pain experienced by patients with spinal cord compression are distinctly different from other types of back pain. It is generally described as a dull ache that does not respond to normal analgesics and is exacerbated by sneezing or coughing. The most distinctive feature is that pain is worse when lying down and relieved by standing (Cervantes and Chirivella, 2004). Other diagnostic signs and symptoms are:

- Pain - in the back, chest or abdomen, depending on the level of the tumour;

- Dull ache;

- Worse when lying down, increasing overnight;

- Exacerbated by coughing, sneezing;

- Relieved by standing;

- Tenderness at the site of the tumour;

- Motor weakness - weakness of legs, difficulty in standing/walking;

- Sensory alterations - numbness, tingling;

- Bladder and bowel sphincter dysfunction - incontinence, retention, constipation.

If spinal cord compression is suspected it is vital to undertake a full assessment, including an accurate medical history, neurological and physical examinations, pain assessment and investigations. An MRI scan of the whole spine will secure an accurate diagnosis. Some spinal abnormalities may be detected on plain X-rays but not all metastatic disease will be identified (Cervantes and Chirivella, 2004).

Superior vena cava obstruction

SVCO is an obstructive emergency that may occur as the result of progression of a malignancy or may be the diagnostic symptom. SVCO is the partial or complete obstruction of blood flow through the superior vena cava into the right atrium and occurs in 3-8% of patients with cancer (Downing, 2001).

The obstruction may be the consequence of compression, invasion, thrombosis or fibrosis and causes severe reduction in the venous return from the head, neck and upper extremities. Some 90% of cases of SVCO are caused by primary lung tumours, lymphomas and metastatic tumours, with almost 85% being caused by lung tumours (Cervantes and Chirivella, 2004).

Because of the venous obstruction and compression, intravenous pressure increases and collateral circulation develops.

In the vast majority of cases the development of SVCO is quite insidious and patients present with a variety of signs and symptoms. In most patients symptoms are uncomfortable rather than life-threatening. However, in the event of severe or rapid cases where there has been little time for collateral circulation to develop, symptoms may be immediately life-threatening (Watson, 2006).

Signs and symptoms of SVCO

The following are signs and symptoms of SVCO (Cervantes and Chirivella, 2004):

- Venous distension in neck and chest;

- Facial oedema;

- Plethora - dilation of superficial blood vessels;

- Proptosis;

- Stridor;

- Oedema of arms;

- Neck and facial swelling (especially eyes);

- Cough;

- Dyspnoea;

- Pressure symptoms, head fullness/headache;

- Hoarseness;

- Nasal congestion/epistaxis;

- Haemoptysis;

- Dizziness;

- Dysphagia;

- Syncope.

Symptoms may be exacerbated by bending forwards or lying down.

SVCO is generally diagnosed by the presence of the signs and symptoms above and confirmed by CT scan, which provides detailed information about site, structure and effect of the tumour. Histology needs to be confirmed where possible to ensure that the most appropriate treatment is provided.

Survival following SVCO generally depends on the underlying cause as opposed to the severity of symptoms, although dysphagia, hoarseness and stridor are accepted to be poor prognostic factors. If SVCO is left untreated it will progress to produce altered mental states including stupor, coma, seizures and ultimately death (Watson, 2006).

Hypercalcaemia

Tumour-induced hypercalcaemia is the most common metabolic disorder associated with cancer (Heatley, 2004) and occurs in 10-20% of all cancer patients (Downing, 2001). It is diagnosed when the corrected serum calcium level is above 2.6mmol/l (Salt, 2003).

Increased release of calcium from the bones is the main factor contributing to hypercalcaemia in patients with cancer but bone metastases are not always present. For many patients, it occurs as a paraneoplastic phenomenon (Salt, 2003). Up to 80% of patients develop hypercalcaemia as the result of parathyroid hormone-related peptide, which causes increased resorption of bone and reduced bone formation with a corresponding increase in serum calcium (Downing, 2001). Altered bone metabolism may also be influenced by the production of cytokines.

Common diagnostic groups include patients with lung, breast, head and neck and renal tumours as well as those with lymphoma and myeloma (Cervantes and Chirivella, 2004). Common signs and symptoms are presented below and their severity is related to the speed of rising serum calcium levels (Watson, 2006). Some of the symptoms may be confused with general symptoms of advancing disease.

Signs and symptoms of hypercalcaemia

- Fatigue;

- Malaise;

- Anorexia;

- Nausea;

- Vomiting;

- Confusion;

- Bone pain;

- Polydypsia, polyurea;

- Constipation;

- Weakness;

- Cardiac arrhythmias.

Increased neurological symptoms if 3.5 mmol/l or greater:

- Confusion;

- Sleepiness;

- Lethargy;

- Coma.

While a comprehensive medical and nursing history will identify symptoms, hypercalcaemia is diagnosed by a blood test.

While patients will have specific needs relating to interventions, all patients living with cancer and awaiting results that may confirm progression of disease need support, education and information. These must be provided by all members of the care-giving team to prevent previously identified deficits in supportive care (NICE, 2004). Time must be spent with the patient, friends and family explaining possible causes, treatment options and influences on prognosis where possible to enable patients to make informed choices about care.

- Part 2 of this unit, which explores treatment regimens and nursing care, will be published in next week’s issue.

Learning objectives

1. Describe the signs and symptoms of each palliative care emergency condition.

2. Identify patients at risk of developing palliative care emergency conditions.

Portfolio pages online

Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.

- For the Portfolio Pages corresponding to this unit, log on to nursingtimes.net, click NT Clinical and Archive then click Guided Learning

This article has been double-blind peer-reviewed.

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