VOL: 103, ISSUE: 34, PAGE NO: 26
Megan Rosser, MSc, PGCE, BSc, DN Cert, RGN is nurse lecturer, School of Health Science, University of Swansea
Before describing the management of patients presenting with a palliative care emergency, it is vital to consider how professionals should approach care. Patients must be at the centre of any treatment decision, so communication with the patient, family and friends is paramount. Adherence to a patient-centred approach also fulfils recent recommendations (NICE, 2004). The patient’s wishes, which may be influenced by the extent of disease, perceived quality of life and prognosis, must be taken into account when planning treatment. Patients may choose pure palliation of symptoms, declining more acute interventions. Conversely, they may be desperate to accept any treatment in the hope of living longer.
Regarding diagnostic tests and investigations, the team should only investigate if the plan is to offer treatment to patients. If the presenting condition is perceived as a pre-terminal event, palliative care is much more appropriate.
MANAGEMENT OF SPINAL CORD COMPRESSION
The aim of any treatment for confirmed spinal cord compression is to preserve or restore neurological function. The key to successful treatment is speed. The earlier the treatment, the more likely the recovery of function. Rapid intervention is vital in order to prevent permanent spinal damage, associated loss of function and corresponding diminished quality of life (Watson, 2006). This is exceptionally important because up to one-third of patients presenting with spinal cord compression will live at least a year after symptoms develop (Faull and Barton, 1998).
For most patients with cord compression and a radiosensitive tumour, radiotherapy and high-dose steroids are generally the treatment of choice (Cervantes and Chirivella, 2004). Therefore, as soon as suspicion of compression occurs, it is necessary to involve an oncologist. If a patient with recent symptoms presents out of hours, it is vital to contact the on-call oncologist and radiotherapist as speed is of the essence.
Each patient should be assessed on an individual basis. Those with complete paresis persisting for a number of days may not be regarded as such a high priority for investigation and treatment.
Steroids are generally given in combination with radiotherapy and a stat dose of dexamethasone 16mg IV is likely to be prescribed with subsequent daily oral doses, reducing gradually. If a patient is very ill, declines radiotherapy or has received maximum radiotherapy to the site already, a trial of steroids may be all that is indicated. Analgesics may also be prescribed for patients with spinal cord compression.
Attention to pain is vital - accurate pain assessment and correct prescribing of analgesics will promote patient comfort. Patients are likely to be prescribed NSAIDs to relieve bone pain and may also require opioid analgesics for other disease-related pains. Nurses should offer advice about possible side-effects; they must observe for signs of adverse responses and advise the medical team should problems arise.
Spinal decompression surgery may be indicated if the compression is the first manifestation of malignancy, the tumour is not radiosensitive, the spine is unstable or the compression is caused by a single metastasis (Cervantes and Chirivella, 2004).
Nursing care for these patients will follow trust guidelines for patients following spinal surgery. Chemotherapy may be prescribed for patients with chemosensitive tumours (Downing, 2001).
Nursing care will be governed by an individual assessment but there will be common nursing needs relating to patients taking steroids and analgesics, and to those receiving radiotherapy.
Trust skin care policies should be adhered to for patients receiving radiotherapy. Nurses need to observe the treatment field for signs of inflammation and skin breakdown, and report these to doctors and radiotherapists.
Patient needs will vary from intensive rehabilitation to total dependence on nursing staff. Specific attention needs to be paid to bowel and bladder care.
All patients require support and education and nurses may refer to specialist palliative care support teams. Patients presenting with a late compression and significantly reduced mobility will require fundamental nursing care to meet all their needs. Preventative measures need to be implemented to prevent problems associated with bedrest.
Liaison with members of the multiprofessional team will ensure provision of appropriate care to enable the patient to return home wherever possible. This includes, for example, involvement of the occupational therapist to look at adaptations to the home, referral to social service carers to attend to hygiene needs and the involvement of community nurses to provide support.
MANAGEMENT OF SVCO
Care is intended to relieve symptoms and possibly cure the underlying disease. Treatment decisions will partly be determined by the histology of the causative tumour and also by other factors including patient health and prognosis. The intensity of treatment will vary according to the expected outcome and patients will generally receive radiotherapy or chemotherapy depending on the histology and sensitivity of the tumour.
If a patient is too unwell, the focus of care is symptom control. The patient may be considered for vena caval stenting. Patients and families will require ongoing support and education about their condition and treatment plans. The efficacy of steroids in superior vena cava obstruction is unproven (Rowell and Gleeson, 2001) and may be prescribed as a matter of personal preference of clinicians. Steroids may be strongly indicated if the patient is too ill or the treatment plan unclear (Salt, 2003).
Nursing care will include appropriate care for breathless patients. If a patient is very breathless, bedrest may be encouraged with the patient sitting upright, supported by pillows. Patients, families and friends will require psychological care and support in response to any anxiety related to the situation. A trial of oxygen should be started but only continued if it helps relieve symptoms (Faull and Burton, 1998). If patients are nursed in bed, nursing care should prevent the complications of bedrest.
If radiotherapy or chemotherapy is prescribed, relevant nursing care should be offered. Patients will also require education about their treatment and psychological support if the SVCO was a diagnostic event.
MANAGEMENT OF HYPERCALCAEMIA
Control of hypercalcaemia will not affect prognosis but may improve symptoms and quality of life. Treatment is indicated when corrected serum calcium levels are above 2.8mmol/l (Salt, 2003).
Intervention is primarily intended to restore normal levels of serum calcium, which in turn will relieve signs and symptoms.
Tumour-induced hypercalcaemia is associated with a low survival rate (Heatley, 2004) and patients tend to experience repeated episodes of hypercalcaemia. Ultimately a patient may present with a final episode of hypercalcaemia for which corrective treatment is no longer appropriate and terminal care becomes the focus.
Immediate medical management is concerned with reducing the serum calcium levels. This is achieved by immediate rehydration. Oral fluids are encouraged and intravenous normal saline infused (Faull and Barton, 1998). Patients will also be prescribed bisphosphonates, which are potent inhibitors of bone resorption and act rapidly to reduce serum calcium levels. Zoledronic acid, with 4mg given in a 15-30 minute infusion, has been proven to be more effective than older bisphosphonates such as pamidronate (Cervantes and Chirivella, 2004).
Maintenance therapy can be provided by regular infusions of zoledronic acid as a day patient or, in some cases, at home. The frequency of infusion will be determined by the rate of the increasing calcium levels. Patients receiving zoledronic acid may experience side-effects such as a transient fever, musculoskeletal pain, gastrointestinal disturbances, fatigue, headache, conjunctivitis and renal impairment. They may develop anaemia, low serum phosphate and calcium (BNF 53, 2007).
Patients will require management of the symptoms resulting from hypercalcaemia. Aperients and suppositories or enemas may be required to correct constipation and anti-emetics such as haloperidol 1.5-3mg nocte will reduce the effect of raised serum calcium on the chemoreceptor trigger zone.
If patients are drowsy or confused they will need reassurance and close surveillance. Stringent mouth care will relieve the oral discomfort of dehydration. All other nursing care will be given according to the patient’s level of functionality and dependence, so individual assessment is vital.
If a patient responds well, further cancer treatments such as chemotherapy or endocrine therapy may be offered with a view to decreasing the productions of the parathyroid hormone and cytokines. These decisions will be governed by factors such as histology, extent of disease, rate of progression, prognosis and patient choice.
Individual assessment is paramount as treatment will be influenced by patient wishes, extent of disease, quality of life and aims of care. Nursing care ranges from psychological care and education for relatively well and recently diagnosed patients to total holistic nursing care of dependent patients to optimise the quality of life that remains.
1. Understand the nursing care that patients will require following a palliative care emergency.
2. Appreciate how different treatment may be appropriate at different stages of a patient’s disease.
- This article has been double-blind peer-reviewed.