Support for family and carers

Support for the family and carer can be one of the most important aspects of the holistic care provided by primary care teams, backed up by hospice support if available. Carer breakdown is often the key factor in prompting institutionalised care for dying patients. Carers should be included as full members of the team, enabled, forewarned, informed, and taught to care for the dying patient to the level desired. This has consequences for the carer in bereavement, with a greater satisfaction that...

Prognosis and causes of death

Age and diabetes are the key factors determining prognosis. The overall one year survival in patients with ESRF on dialysis is 84 , but the five year survival of a young person who does not have diabetes is 74 while that of someone aged > 65 with diabetes is 21 . The most common cause of death is cardiovascular disease. A considerable number of patients choose to stop dialysis, and a further group opts for initial conservative management (without dialysis). Patients who choose to stop...

Mindbody therapies

The aim of these therapies is to alter the quality of an individual's thoughts and thought processes. This could lead to psychological and possibly physiological change. As well as simple relaxation there is classical meditation involving various techniques Patients are said to be able to overcome physical and emotional problems by imagining positive images and desired outcomes to specific situations, either alone or helped by a practitioner in a process known as guided imagery A large body of...

Gastrointestinal obstruction

Malignant obstruction of the gastrointestinal tract may be due to occlusion of the lumen by tumour or distortion of gut and mesentery by tumour, or may be functional due to a failure of normal peristalsis. Obstruction may be partial or complete and may develop gradually with self resolving episodes of partial obstruction preceding a complete obstruction. The treatment of choice for a single level of occlusion is surgery, but when the patient is unfit for surgery, or when there are multiple...

Recognising the preterminal phase and end of life care

Increasing admissions to hospital and severity of pain and other symptoms with decreasing performance status often presage the terminal phase of the disease. For example, the pain of calciphylaxis, or peripheral vascular disease, with consequent amputations is known to be associated with a poor prognosis. Introducing palliative care at this stage not only enables better symptom control but can help the passage into end of life care if a decision to stop dialysis is taken. Discussion earlier in...

Dry mouth xerostomia

Xerostomia may be caused by a reduction in the secretion of saliva, a change in the composition of saliva, or a combination of these factors. Xerostomia is associated with several other oral symptoms and problems, including oral discomfort, disturbance in taste, difficulty chewing, difficulty swallowing, difficulty speaking, difficulty in retaining dentures, dental caries, oral candidosis, and other oral infections. The various manifestations of xerostomia reflect the multiple functions of...

Breathlessness cough and other respiratory problems

Respiratory problems are common in patients with advanced incurable disease. This article describes palliation in adults with malignant disease, but the principles can be applied to many types of non-malignant disease. A detailed history, examination, and appropriate investigations are needed to establish the most likely cause of any symptom. The degree of functional impairment should be assessed, as should the influence of factors that affect the severity of the symptom, including pre-existing...

Information on the terminal phase

At the onset of dyspnoea or symptoms of chronic hypoventilation or when the forced vital capacity drops below 50 , patients should be offered information about the terminal phase as at this point they fear that they will choke to death. Describing the mechanism of terminal hypercapnic coma and the resulting peaceful death during sleep can relieve this fear. More than 90 of patients die peacefully, mostly in their sleep. The death process usually begins with the patients slipping from sleep into...

The principles of control of cancer pain

Twycross Total Pain

Marie Fallon, Geoffrey Hanks, Nathan Cherny Factors affecting patient's perceptions of pain adapted from Twycross RG, Lack SA, Therapeutics in terminal disease, London Pitman, 1984 Pain is a complex phenomenon which is the subjective endpoint of a variety of physical and non-physical factors. For most patients, physical pain is only one of several symptoms of cancer. Relief of pain should therefore be seen as part of a comprehensive pattern of care encompassing the physical, psychological,...