Cornwall GP Trainers' Workshop Web Site

Representatives from 19 Cornwall general practices took part in local prescribing workshops during October 1999 to discuss the management of terminal care and the use of sipfeeds. There was consensus on some key management options. Where appropriate, we include comments from Drs Sharon Ife and Peter Hargreaves at Mount Edgcumbe Hospice.

There is little doubt that the symptom dominant in the minds of patients, family and carers is pain. The total pain experienced by the patient is a complex of their physical pain (both acute and chronic) and any depression, anger and anxiety that they may be experiencing. Good pain relief may therefore require attention to these factors. It was emphasised that there is benefit in speaking to the patient with his/her spouse present, and defusing future problems by asking about their fears before any tests are done, so that they are already vocalising concerns rather than suppressing them.

The analgesic ladder was well-known, as was the importance of treating "by the ladder and by the clock". Immediate release oral morphine is useful in acute pain. When necessary, sustained release morphine could be introduced. Oramorph SR is cheaper than MST tablets, but has a reduced range of strengths and no liquid formulation. When the patient has an ileostomy or high obstruction there may be insufficient intestine available for complete absorption of a sustained release dose, and 4-hourly dosing may be necessary using standard solutions. Oramorph 10mg/5ml solution is not a fully controlled drug, which is helpful if a pharmacy has to be telephoned for a first supply with the prescription forwarded later. Fentanyl patches have become popular for pain relief. When changing from oral morphine to fentanyl a rough guide is that 90mg daily of oral morphine would equate to a 25mcg patch. Some doctors liked oxycodone suppositories, but these are only available as a special order.

When the various types of pain were examined, it was noted that opioids are not the only option, nor first choice in most cases.

Pain type - Suggested therapies

Bone - NSAIDs, radiotherapy, (pinning long bone fracures, nerve block)

Nerve - compression:- Standard analgesics, steroids, TENS

- stabbing:- Carbamazepine, valproate, phenytoin, TENS

- neuropathic:- Tricyclics, steroids, TENS

Pleuritic:- Antibiotics for proven infection, NSAIDs, nerve block

Headache:- Dexamethasone (1mg = ~ 7mg prednisolone)

Visceral:- Standard analgesics, steroids

Colic:- (Deal with any constipation or obstruction and re-assess)

For drug-induced nausea and vomiting haloperidol is first choice, though cyclizine acts on the vomiting centre directly and may help whatever the cause. However, in very high dose (>250mg/10ml) cyclizine may cause diamorphine to precipitate in syringe drivers. Methotrimeprazine (now named levomepromazine) is often used, and smaller doses than have customarily been used in the past may be effective for nausea and vomiting eg 12.5mg subcutaneously over 24 hours may be adequate and avoid undue sedation. Methotrimeprazine may cause injection site problems in some patients. Where a syringe driver is not in place, domperidone suppositories are useful.

The role of the family was briefly explored. It is easy to forget that the rest of the family may be anxious or depressed, and modern management by specialists such as Macmillan nurses can leave the relatives feeling marginalised, with nothing practical to do. This can be avoided by encouraging them to prepare enticing meals, massaging immobile limbs or giving abdominal massage in the case of constipation. The importance of keeping rooms ventilated and not worrying if the patient’s appetite declines should be explained to them at the outset.

The causes of anorexia were looked at. It was noted that families need to be educated into not trying to overfeed a patient, and that small, tempting meals are more use than bulky food. One GP suggested that a chopped-up Mars ice-cream bar contains over 300 calories and is accepted by most patients. Steroids or megestrol acetate if steroids are contra-indicated may restore appetite. Before sipfeeds are tried, enhancement of standard food should be instituted, and a leaflet is available from NAGE or the dietitians which explains how to do this.

Constipation is to be expected with opioids. When co-danthramer or co-danthrusate are used then families should be warned that these may stain stools and urine. Additional stimulant laxatives (senna or bisacodyl) would be used if constipation remains a problem. Doses of stimulants may need to exceed those on the data sheet. There is little or no place for lactulose in terminal care.

Miscellanea - the effective dose of diamorphine in children is often higher than might be expected - up to double that in adults, weight for weight. Tension may occasionally arise between the GP and the Macmillan nurses if therapy changes are suggested in front of the patient or family without prior discussion with the GP, especially if the evidence base behind some of the suggestions is unclear. Nebulised diamorphine or bupivacaine has been tried in intractable cough with mixed results. GPs were reminded that many patients in terminal care qualify for free prescriptions under the catchall that they are unable to leave home.

SIPFEEDS

The overall cost of sipfeeds is rising but there is little evidence that this is associated with improved care. Most surveys suggest high levels of waste, and many GPs were unhappy that the decision to use sipfeeds was being taken by others.

The key messages to regaining control were:

• record the indication for which they are used and who suggested them; monitor weight, height, BMI, Us & Es, total protein and albumin and haemoglobin;
• repeat monitoring fortnightly;
• prescribe small quantities in assorted flavours;
• Remind homes that these are drugs, to be recorded on the patient’s records when given and not to be used as commodities.

MIMS distinguishes between those which are complete sources of nutrition and those which are not.

An assessment sheet to facilitate initiation was suggested and is attached. GPs are welcome to copy it at will. GPs should remember that the local dietetic department is happy to provide advice.

For full prescribing information on any of the drugs mentioned please consult individual Data Sheets/Summary of Product Characteristics and the current BNF

Please send any comments to Michael Wilcock , Pharmaceutical Adviser, Cornwall & IoS HA, John Keay House, St Austell PL25 4NQ.

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