Adult Medical Emergency Handbook - Scottish Intensive Care Society

EMERGENCIES IN PALLIATIVE CARE
Emergencies in Palliative Care
Introduction
• Patients receiving palliative care may deteriorate suddenly due to their illness or another acute
medical or surgical problem.
• Management options depend on life expectancy, level of intervention needed, and an
assessment of risks, benefits, side effects and likely outcome.
• Symptom control and supportive care may be the most appropriate management if the patient
is dying. (see: Last days of life)
• Discuss treatment options with the patient and family. If possible discuss and document
the patient’s wishes in advance including those about resuscitation, hospital admission and
transfer to an intensive care unit.
• Emergency treatment can be given but ongoing treatment in a patient lacking capacity to
consent 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 compression
Bleeding
• 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 for
use 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 of
hours services.
Management of severe, acute bleeding
Non-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 for
haemorrhage.
• If the patient has a massive haemorrhage and is clearly dying, support and non-drug
interventions are more important until help arrives than trying to give sedative medication as
the patient will usually lose consciousness rapidly.
Sedative medication
• If the patient is distressed, titrated doses of a rapidly acting benzodiazepine are indicated. The
route of administration guides the choice of drug.
o IV access available: midazolam 5-20mg IV or diazepam (emulsion for IV injection) 5-20mg IV
in 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 buccal
liquid (special order product).
http://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/A-Z/PalliativeCare/
PalliativeCareGuidelines
246 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11