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Palliative Care Palliative Care is given to improve the quality of life of patients who have a serious or life-threatening disease.

The goal of palliative care is to prevent or treat as early as possible the symptoms of the disease, side effects caused by treatment of the disease, and psychological, social, and spiritual problems related to the disease or its treatment. It can also be called comfort care, supportive care, and symptom management. Palliative Management of the bleeding patient General supportive measures 1. Identify the patient at risk 2. Establish open communication of issues of care 3. Generate care plan 4. Consider measures for catastrophic bleeding 5. Use of sedatives (midazolam hydrochloride) 6. Revisit as required by patient course Local measure 1. Packing 2. Compressive dressings and postures 3. Topical hemostatics (collagen, thrombin, fibrin gel, antifibrinolytics) 4. Topical astringents or vasoconstrictors (silver nitrate, alum, formaldehyde, cocaine, epinephrine) Special techniques 1. Endoscopic interventions (cauterization, sclerosis, ligation) 2. Interventional radiology (vascular embolization) 3. Palliative radiotherapy 4. Palliative surgery (vascular ligation) Systemic interventions

1. Discontinue antiplatelet and antithrombotic medications 2. Vitamin K administration 3. Antifibrinolytic medication (tranexamic acid, -aminocaproic acid) 4. Transfusion support (platelets or plasma for hemostatic support, red cells for symptomatic anemia) 5. Desmopressin 6. Somatostatin analogs (ocreotide acetate)

BLEEDING Management of bleeding depends in its site and severity. Management options may include: 1. Topical adrenaline and/or aliginate dressings. 2. Palliative radiotherapy 3. Tranexamic acid 4. Reversal of warfarin 5. Transfusion 6. Laser 7. Alum solution 8. Radiation menopause 9. Sedation in severe bleeding 1. Liberal use of topical adrenaline (1 in 1,000) on a dressing, applied with firm local pressure, is a good first aid measure for surface bleeding. If infection is contributing to bleeding give a broad spectrum antibiotic. Alginate dressings are hemostatic and can be useful for surface bleeding. (see Pressure Sores) 2. Palliative radiotherapy can dry up surface bleeding from fungating breast cancer or malignant nodes and is often effective for hemoptysis. It cannot be given if the area has already received radical doses of radiation. 3. Oral tranexamic acid 1g per day can stop capillary bleeding. It is an anti-

fibrinolytic and acts by stabilizing the fibrin plug. It can cause nausea. Antifibrinolytics are said to increase the risk of clots forming in the bladder in patients with hematuria. Clots in the bladder can be lysed by citrate bladder washouts. 4. If the patient is taking warfarin the effect can be reversed by giving Vitamin K, phytonadione 10mg orally (which reverses warfarin in 4 hours), or 10mg IV by slow injection to avoid nausea (which has immediate effect). Warfarin should be reversed in the terminal phase of illness to prevent the distressing bleeding that can occur as the patient dies, causing altered blood to trickle from the mouth. If warfarin overdosage has caused hypothrombinemia and bleeding, fresh frozen plasma replaces clotting factors immediately. 5. Blood transfusion is not usually considered for active bleeding in terminal illness, unless the bleeding is controlled and the patient is left with symptomatic anemia. (In fact, transfusion can make bleeding heavier for a time.) 6. Laser therapy can coagulate bleeding tumors in the bronchus and rectum. It can be performed through an endoscope and has the advantages of immediate relief of symptoms without systemic side effects. It usually has to be repeated. Standard (no-touch) laser techniques may not control heavy bleeding from large, friable cancers. Such bleeding has been controlled in gastric cancers using lowpower interstitial laser coagulation. 7. A 1% alum solution (100mg alum dissolved in 1,000ml sterile water, then diluted x 10 with normal saline) is the best styptic solution for bladder washouts to control bladder hemorrhage, and on ribbon gauze to control hemorrhage from carcinoma of the rectum. 8. Heavy menstrual bleeding can be troublesome for a disabled patient (with

ALS, for example) and can be stopped by inducing a radiation menopause. 9. If severe bleeding and shock occurs, the patient should be sedated (with an injection of morphine, scopolamine and chlorpromazine). If a sudden massive hemorrhage is a strong possibility, these drugs should be kept ready in a syringe. A red blanket should also be readily available to reduce the visual effects of massive hemorrhage.

Bleeding can sometimes occur in cancer especially as the disease progresses

Patients and families can be very distressed by even small amounts of visible bleeding

ASSESSMENT It is important to make an assessment of the cause, the severity and the prognosis of the patient when assessing bleeding When appropriate carry out relevant tests including a coagulation screen

MANAGEMENT Treatment of bleeding in palliative patients depends on the patients prognosis and whether the treatment is likely to be effective

Consider if patient is well enough to benefit

General Measures Reassure and explain the situation to patient and family General supportive measures including fluid replacement if the bleeding is severe Stop medications such as NSAIDs or anticoagulants that may be causing or exacerbating the bleeding Consider correcting any abnormal clotting, i.e. with Vit K or fresh frozen plasma if available

Bleeding from Bladder May benefit from continuous bladder irrigation and instillation of haemostatic agents If well enough consider cystoscopy/diathermy Tranexamic acid should be used with caution in genitourinary bleeding as clot formation may be problematic

Bleeding from Mouth/Gums Cautious cleaning of the mouth Tranexamic acid IV liquid (diluted 50:50 with water) as mouthwash may be useful

Transfusion when Appropriate Other Tranexamic acid: adult 1 g tid PO or IV Packed red cells Platelets

Bleeding from Nose Can be stopped by continuous pressure Use silver nitrate sticks Packing for 15 minutes with gauze soaked in 1:1000 adrenaline/epinephrine

Tranexamic acid o 10-20 mg/kg bid to tid IV o 25 mg/kg/dose tid to qid PO

Massive Haemorrhage in Terminal Phase Stay with patient Reassure family If appropriate sedate patient with midazolam 5 mg-10 mg SC/IV stat Use dark green or blue towels to disguise blood

Consider haemostatic radiation or embolisation

Bleeding from a Wound/Ulcer Apply steady pressure Adrenaline/epinephrine (1:1000) impregnated dressings

PITFALLS/CONCERNS If a massive haemorrhage is likely at some stage the family and patient should be prepared for this as far as is possible Do not use tranexamic acid when disseminated intravascular coagulation (DIC) is suspected

Bleeding from GI Tract Stop NSAIDS and reduce and discontinue steroids if possible Start omeprazole, ranitidine or similar medication Endoscopy if possible and if warranted

PALLIATIVE TIPS Patients with advanced liver disease or renal failure may develop impaired clotting complicating this problem In addition, they may have been started previously on anticoagulants for another problem

Management of Common Symptoms in Terminally Ill Patients Junior Rotation in Hospice and Palliative Care Symptom Prevalence (Cancer, AIDS, many other terminal conditions) 1. Fatigue 2. Anorexia 3. [Pain] 4. Nausea 5. Constipation 6. Altered mental states (delirium) 7. Dyspnea General Approach to Symptom Management at End-of-Life Search for cause of symptom History, physical, laboratory (as appropriate) Treat underlying cause (if reasonable) Treat the symptom Re-evaluate frequently Fatigue Most common symptom in medicine Lack of energy, tiredness Subjective weakness Diminished mental capacity Not relieved by rest May be incapacitating Diagnosis of Fatigue Often under diagnosed or ignored

Multidimensional assessment tools available The Brief Fatigue Inventory (BFI) http://prg.mdanderson.org/bfi.pdf Pathogenesis of Fatigue Physical causes Decreased O2 carrying capacity: Anemia or CHF Cancer, chronic illnesses Treatments for cancer, HBP, other Psychological causes Anxiety and / or depression Erythropoietin and Fatigue in Terminal Illness May benefit selected patients Symptomatic anemia Low erythropoietin levels Considerations: Cost Time to effect (4 to 6 weeks) Palliative treatment of Fatigue Nonpharmacologic therapy Patient/family education: Permission to be tired Energy conservation strategies Pharmacologic therapy Dexamethasone 2-20 mg qAM Methylphenidate 2.5-5 mg qAM and noon Antidepressant trial (SSRI) References: http://books.google.com.ph/books?id=Ln gD6RFXY_AC&pg=PA353&lpg=PA353&dq =palliative+management+for+bleeding&s ource=bl&ots=TK8CDbTy30&sig=TATCupg kPpcpkpYrERnJ4xj_J_A&hl=tl&sa=X&ei=e LtQT_-_OYjiAfzmuXJCw&ved=0CH0Q6AEwCQ#v=on epage&q=palliative%20management%20f or%20bleeding&f=false