Palliative care emergencies 

Often when we understand someone is palliative, it is sometimes assumed that an emergency circumstance does not exist. This is untrue. It is true to say we are unable to deal with the underlying problem that has caused the emergency events but there are steps and protocols we can follow in order to alleviate pain and or other symptoms that could be causing distress and discomfort and overall add to the quality of life the patient has left. 

We are lucky that Palliative care has progressed so much over the last decade that certain events that occur during the end of our life can be managed in a more dignified and less traumatic manner for the patient and the family. Here are a list of the palliative emergencies you could find with a palliative patient, how to recognize and how to treat: 

• Spinal Cord Compression

• Hypercalcaemia

• Haemorrhage

• Seizure

• SVC obstruction

• Neutropenic Sepsis

• Emotional/spiritual

• Social

• Emergency discharge

It is important before recognizing you have a palliative care emergency on your hands to also consider the following: 

Anticipate the likelihood of an emergency arising: Is your patient a high risk patient in any of the above? For example if you have a neurological disorder or brain tumour this could mean you are at a higher risk of seizures. Does your patient have an open tumour that is beginning to look vascular? This could mean that they have a higher risk of haemorrhaging. Perhaps your patient is thrombocytopenia or is on medications such as some neuropathic nerve agents which can also add to reducing the platelet count, these patients may need a crisis pack in the circumstance they do haemorrhage. These are only a few examples linking different conditions to the increased risk of these emergencies. It is important to be aware and knowledgeable about your patients past medical history as well as their current in order to ensure what risk they are at. Anticipating for a palliative care emergency means you have more chance of being prepared for one if it does occur. This can often involve difficult and emotive conversations between yourself and the patient. It is vital to be up front and explain to the patient what they would want to happen in the chance of this emergency happening, this could mean hospital admission. Sometimes it is useful to encourage the patient the reason we are having this discussion is for precaution and not to add fear, we need to plan for the worst but always hope for the best. 

Early Recognition, being aware of signs and symptoms to look out for can be crucial to detect if a palliative care emergency may be brewing. These signs and symptoms will be discussed further down. Early recognition can be crucial in distinguishing between what may be symptoms from the patients underlying disease and not a palliative emergency. 

Appropriate Response, in my opinion, this is one of the most challenging parts in recognizing and acting on a palliative emergency. Treating a palliative patient, at times a palliative care emergency can often present itself in the same way that a terminal event can also. Making the judgement call whether this is a palliative emergency or whether this is in fact a terminal event can be hard to differentiate. It is important to try and think outside the box and take yourself out of the situation and ask yourself is the situation you are in right now reversible? Is the patient going into hospital for a reversible cause? Does the burden of having an invasive procedure outweigh the benefit, will there be a benefit? This conversation links in to the first point of ‘Anticipating the likelihood of an emergency arising’ being frank and honest with the Patient and family member’s about the condition of the patient and the reality of what  would happen if the patient would want intervention even if it was not advised by medical professionals. 

Why do we treat Palliative care emergencies if the outcome is going to be death? This is a question that patients and their families have often bought up. The patient and family members have often found the above topic of conversations laborious and ‘like pulling teeth’, ‘an agonising taunt to what the end will be like’. There are a number of reasons why we treat the palliative care emergencies such as: 

• Improvement in quality of life

• Symptom management

• Prolong life

• Less complicated bereavement by having an interventions.- this particular reason can be linked to the Reflective piece in this blog called ‘ The patients Family’ When a patient dies and the family and friends are grieving, a common sign of grief we see at times is the guilt and blame the family and friends have after their relative has died. Bartering between what they should have done different. If a patient and family are particularly passionate and strong-willed about how far they will go to have medical intervention despite a patient being gravely unwell. This may help them in terms of dealing with the death, feeling as if they had tried every avenue and medical intervention possible.

Clare Troy