Case-based discussion for palliative care

Scenario 1 Scenario 2 Scenario 3

Case 41 man with metastatic colon ca. started 74 male with prostate ca and bone mets; 68 male at respiratory clinic; dx with
OPIOIDS 5 days ago, now c/o nausea, has lower back pain (lumbar spine bone COPD in 2010 – reduced QOL; SOB at
abdominal discomfort, he is pale, mets); pain onset is intermittent and suddenrest, worsening in the past 4 weeks, now
dehydrated. (lasts HOURS). Regular oral IBUPROFEN 400 immobile due to SOB; 3 admissions in
1. Dehydrated mg TDS and oral immediate release past 5 months due to AECOPD; now
2. Nauseated morphine PRN 10mg BD reluctant to go to ED for future
3. Discomfort 1. Lower back pain episodes. Anxious about his future.
4. Pale 2. Prostatism 1. DVT/PE
5. Anorexia 3. UTI symptoms 2. SOB
4. SOB due to severe pain 3. Pressure sores
5. Immobility (loss of function) 4. Depression
6. LGIB/UGIB 5. Side effect of steroids
3 further 1. Passing flatus, intestinal 1. Features of hypercalcemia 1. Medication history
details in obstruction, constipation symptoms 2. Social background
history 2. Urine and bowel output 2. Prostatism and UTI sx 3. Advanced directive because
3. Opioid type + dose + usage of 3. Incontinence due to spinal cord worried about future options
breakthrough pain involvement esp if new symptoms of 4. Features of cor pulmonale
4. Poor oral intake back pain (saddle anesthesia, new 5. Features of DVT
5. Hypercalcemia symptoms urinary retention) 6. Risk factors for DVT
6. Any recent UGIB/LGIB – taking any 4. CES symptoms like saddle 7. Family history of clotting
NSAIDS for painkiller anesthesia disorders
8. Any recent lung infections –TB
(MM – URINARY OVERFLOW symptoms, LRTI
FOLLOWED BY URINARY RETENTION 9. Vaccination history
DEPENDING ON LEVEL OF CORD 10. Home conditions – for
AFFECTED) domiciliary LTOT
DDX 1. Colon ca 1. Pathological fractures due to bone 1. AECOPD
2. Opioid side effect mets 2. Corpulmonale decompensating
3. Liver mets 2. Inadequate analgesia 3. PE microinfarcts
3. MM/TB SPINE 4. Anxiety
Investigations CECT Spine XR followed by Spine CT lateral i/v/o FEV as palliative care indictor and
AXR cord involvement prognosticator
PR CXR
Blood and sputum C/S
3 main steps 1. Fluid for dehydration 1. Analgesia – morphine 10MG QID 1. Titrated oxygen +chest physio +
of 2. If constipation – stool softener 2. Bisphosphonates to stabilize DVT prx
management 3. Nausea – fractures 2. Counsel for LTOT after
in each case 4. Dexamethasone to reduce 3. Add 2.5mg to established dose and discussing prognosis
gastrointestinal edema reassess after 24 hours , then 3. Discuss prognosis with patient
5. Surgical – stenting OR palliative recalculate rescue dose 4. Family conference to discuss his
laparoscopic ileostomy 4. Palliative RTX to reduce pain due to health before counselling for
compression of bone/nerves by LTOT
mass/ improve lung obstruction 5. Advanced care planning
5 common medications in palliative care with side effects
1 NSAIDS GIB, renal toxicity
2 ANTIEMETICS Seizure threshold reduced, constipation
3 OPIOIDS Constipation, nausea, respiratory depression
4 STEROIDS Cushingoid
5 LAXATIVES Bloating, cramping, diarrhea
5 conditions excluding malignancy and outline one symptom relevant to each condition which needs palliation
1 HIV Pruritus, persistent cough, diarrhea, fatigue
2 CCF NHYA ¾ SOB
3 COPD GOLD D (<30% SOB
FEV1)
4 ADVANCED DEMENTIA Dysphagia
5 Motor neurone disease Dysphagia, respiratory failure