Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: Emergencies in Palliative CareEmergencies in Palliative CareIntroduction• Patients receiving palliative care may deteriorate suddenly due to their illness or another acutemedical or surgical problem.• Management options depend on life expectancy, level of intervention needed, and anassessment of risks, benefits, side effects and likely outcome.• Symptom control and supportive care may be the most appropriate management if the patientis dying. (see: Last days of life)• Discuss treatment options with the patient and family. If possible discuss and documentthe patient’s wishes in advance including those about resuscitation, hospital admission andtransfer to an intensive care unit.• Emergency treatment can be given but ongoing treatment in a patient lacking capacity toconsent requires a Section 47 Certificate. (see: Adults with Incapacity Act on website)• This guideline covers the following palliative care emergencies:• Bleeding events• Hypercalcaemia• Seizures• Spinal cord compressionBleeding• Acute haemorrhage can be very distressing for the patient and family.• It is usually best to discuss the possibility with the patient and their family.• An anticipatory care plan is helpful. This includes having sedative medication prescribed foruse if needed.• If the patient is at home, discuss options for sedation if family carers feel able to use these.• Discuss resuscitation; document and communicate resuscitation status.• Make sure all professionals / services involved are aware of the care plan, including out ofhours services.Management of severe, acute bleedingNon-drug• Call for help. Ensure carers at home have an emergency contact number.• Put the patient in the recovery position.• Apply direct pressure to any bleeding area; dark coloured towels are best.• If resuscitation is appropriate, admit to hospital and manage according to local protocols forhaemorrhage.• If the patient has a massive haemorrhage and is clearly dying, support and non-druginterventions are more important until help arrives than trying to give sedative medication asthe patient will usually lose consciousness rapidly.Sedative medication• If the patient is distressed, titrated doses of a rapidly acting benzodiazepine are indicated. Theroute of administration guides the choice of drug.o IV access available: midazolam 5-20mg IV or diazepam (emulsion for IV injection) 5-20mg IVin small boluses until settled.o IM injection: midazolam IM 5-10mg can be given into the deltoid muscle.o Rectal route or via a stoma: diazepam rectal solution 5-10mg.o Sublingual: midazolam 10mg can be given using the parenteral preparation or the buccalliquid (special order product).© NHS Lothian Issue date: January 2009 Review date: March 20121