End of Life CareEnd of Life CareDr Anant SachdevGPSI Palliative Medicine

07976 608871anant.sachdev@nhs.net

Learning objectivesLearning objectivesUrological Cancer symptoms in

End of LifeIdentify those at risk from the

following 2 serious clinical scenarios

Understand treatment optionsRefer appropriatelyGeneral principles

SymptomsSymptoms• Pain• Malaise, Fatigue & Cachexia• GI: Poor appetite, nausea• Weight loss• Bleeding• Incontinence• Delirium • Spinal Cord Compression• Hypercalcaemia

Malignant spinal cord Malignant spinal cord compressioncompression

First contact is usually primary health care team!

Common Significant impact on QOL and

survivalRequires rapid decision making

IncidenceIncidence

5% of all cancers in final 2 years Presenting feature

ACUP, NHL, myeloma and lung Decreases with age, but 90% are

>50yrs Depends on primary site

60% are lung, prostate or breastNHL, Multiple myeloma and renal (5-10%)

Colorectal, ACUP and sarcomas

PathophysiologyPathophysiology

Vertebral body mass – anterior compression

Vertebral body collapseDirect tumour growth through

vertebral neural foramen (lymphoma)

Metastases in epidural space (rare)

Clinical featuresClinical featuresLocalisation Localisation

60-80% thoracic spine15-30% lumbosacral<10% cervical50% have more than 1 level

Clinical featuresClinical featuresPain – early sign

Up to 95% for 8/52 localised then radicular Worse when

recumbent valsalva manoevre Neck flexion/SLR

Motor deficits – late sign 60-85% weakness at diagnosis 2/3 non ambulatory at diagnosis Thoracic>lumbosacral

Clinical featuresClinical features

Sensory deficits – late sign 40-90% at diagnosis Sensory level 1-5 segments below lesion Lhermitte’s sign

Autonomic deficits – late sign Urinary retention most common. 50% catheter dependent at diagnosis. Unlikely to be an isolated sign.

InvestigationInvestigationPlain Xray

False negative 17%

Bone scan Back pain + negative bone scan & plain xray

unlikely to have SCC

CT MyelographyMRI

Sensitivity 93%, specificity 97% Diagnostic accuracy 95% Multi level common therefore image entire

spine

Spinal Cord CompressionSpinal Cord CompressionTreatmentTreatment Corticosteroids

8mg BD (morning and lunchtime) and PPI cover Random daily BMs

Bed rest and pressure area care Bowel care RT (early as poss)

1# for pain mgt if no poss of recovery; 5# for treatment

Surgery Early rehab

Recurrent Spinal Cord CompressionRecurrent Spinal Cord Compression

10% pt will develop local recurrence

25-50% pts surviving > 1 yr will experience local relapse.

Mgt – surgery (may be inappropriate); Re-irradiation; supportive and palliative care

Spinal Cord CompressionSpinal Cord CompressionPrognosisPrognosisMedian survival is 3-6 months If ambulatory pre compression 8-10

monthsNon-ambulatory pre compression 2-4

monthsPrimary tumour myeloma / lymphoma – 6-9

monthsPrimary tumour lung – 2-3 months

Almost all patients have recurrence within 3 years

Referral guidelinesReferral guidelinesImmediate investigation (same day)

◦ New onset weakness +/- sensory symptoms +/- autonomic symptoms

◦ Prescribe steroid + PPI

Urgent investigation◦ Persistent severe back pain/nerve root pain without neurological

symptoms if: High risk group Thoracic pain Recumbent pain Exacerbated by valsalva manoevre/Lhermitte’s sign

No investigation◦ Too frail for treatment◦ Very short life expectancy (weeks)◦ Already irradiated to tolerance or unfit for neurosurgery◦ So disabled, cord compression will not effect overall

mobility

Key pointsKey pointsCommonPoor outcome unless early

diagnosisPain is the keySubtle motor changesNeurological deficit is too lateBe aware of:

High risk groups Clinical features

Hypercalcaemia in Advanced Hypercalcaemia in Advanced CancerCancer The Commonest life-threatening

metabolic emergency associated with advanced cancer

A condition which is usually amenable to treatment

If untreated distressing and fatal Always consider when there is

deterioration for no clear cause

Definition?

HypercalcaemiaHypercalcaemia

Defined as corrected plasma calcium >2.6mmol/l

Significant symptoms usually develop above >3.0

Levels > 4.0 are fatal if untreated in a few days

HypercalcaemiaHypercalcaemia

Incidence◦10 – 20% of all cancer patients◦Up to 20% of patients develop

hypercalcaemia without bone metastases

◦Common cancers: bronchial, breast, myeloma, prostate

◦Rare in gastric/colorectal cancer

HypercalcaemiaHypercalcaemia

Cause / risk factors:◦Bone metastases◦PTHrP – secreting tumours e.g. Lung Cancer

◦Dehydration, renal impairment◦Tamoxifen flare

HypercalcaemiaHypercalcaemia

Pathogenesis:◦ Increased bone resorption (osteolysis) and systemic

release of humoral hypercalcaemic factors◦ Calcium is released from bone, and in addition

there is may be a decrease in excretion of urinary calcium

Calcium release from bone by production of locally active substances produced by bone metastases: ◦ Parathyroid hormone related peptide, ◦ Ectopic parathyroid secretion◦ Tumour mediated calcitriol production◦ (Some may occur with or without bone mets.)

• Anorexia• Weight loss• Nausea and vomiting• Constipation / ileus

General

• Dehydration• Polydipsia• Polyuria• Pruritis

Recognising Hypercalcaemia

Neurological

• Fatigue • Confusion

• Myopathy • Seizures

• Psychosis • Coma

Cardiac

• Bradycardia

• Atrial arrhythmias

• Ventricular arrhythmias

• Cardiac asystole

• Death

GI

PrognosisPrognosis

Indicates disseminated Disease

Poor prognosis 80% die within 1

year

Median survival is 3 to 4 months

Hypercalcaemia likely to recur

HypercalcaemiaHypercalcaemia

Treatment may not be necessary if:

the patient is very near to death

or there are no symptoms

distressing the patient

Treatments of Treatments of HypercalcaemiaHypercalcaemia

All treatments involve the correction of

serum calcium levels, which results in a

marked decrease in symptoms

Rehydration Bisphosphonates Steroids

Treatments of Treatments of HypercalcaemiaHypercalcaemia

Rehydration: Dehydration due to vomiting and polyuria, large volume will lower calcium levels, note fluid-overload! 2-3 L/day usually Avoid concomitant use of diuretics, Vitamin A and D which promote hypercalcaemia

Treatments of Treatments of HypercalcaemiaHypercalcaemia

Steroids:◦Have been shown to inhibit

osteoclast activity and calcium absorption from the gut in vitro

◦Limited to haematological and Breast malignancies when oral prednisolone 40-100mg/day is usually effective

Treatments of Treatments of HypercalcaemiaHypercalcaemia

Bisphosphonates

◦Reduce bone resorption by inhibiting osteoclast activity

◦Highly effective◦But take 48 hours to be effective◦Mainstay of hypercalcaemia

treatment◦Further benefit is that of reduction

of bone pain due to metastases

TreatmentTreatment

Dehydration should be corrected with iv fluids

Most common choices of drug IV:◦ Zolendronic Acid: 4mg over 15 minutes◦ Disodium Pamidronate: 30-90 mg over 2-4

hoursEffect seen after 4 - 7 daysLasts 2-4 weeks, many patients have

monthly infusions20% patients with hypercalcaemia will

be resistant to infusion therapy

General EOL principles to General EOL principles to follow:follow:

Review patient regularly - holistically Get District nurses involved early, others eg Macmillan Inform Out of Hours, and practice team - & update! Ascertain PPOC Review symptoms and drugs Communicate well with patient, family and carers

◦ Explain management of crises, ◦ whom to contact, ◦ use of 999, ◦ possible pathway for illness and symptoms expected

when deteriorates,◦ ethical issues : nutrition, hydration, use of ab,

oxygen,◦ supportive measures available, financial help◦ (DS1500)

Consider Just-in-Case medication Consider DNACPR statement

All of the above - Adopt the Liverpool Care Pathway for holistic management of the dying patient

Thank you

Dr Anant Sachdev 07976 608871

anant.sachdev@nhs.net

any Q any Q