Handbook of Palliative Medicine in Malaysia

4
HANDBOOK OF
PALLIATIVE MEDICINE
IN MALAYSIA

Edited by
Richard B.L. Lim
Diana Katiman
CONTENT

Message f rom t he P resident o f C ollege o f P hysicians,

Academy o f M edicine, M alaysia

PAGE
Message f rom t he N ational A dvisor f or P alliative M edicine,

Ministry o f H ealth, M alaysia

11

Palliative C are: D efinition a nd C oncept
12
Section 1 : M anagement o f P hysical S ymptoms
Chapter 1 : C ancer P ain
14
Chapter 2 : R espiratory S ymptoms
20
Chapter 3 : G astrointestinal S ymptoms
25
Chapter 4 : N eurological S ymptoms
31
Chapter 5 : O ral C are
36
Chapter 6 : S kin C are
40
Section 2 : P sychosocial C are, S piritual C are a nd C ommunications
Chapter 7 : D epression
45
Chapter 8 : S piritual C are
47
Chapter 9 : R eligious D iversity
49
Chapter 1 0: C ommunication S kills
54
Chapter 1 1: H andling E motions
59
Section 3 : E nd-of-Life C are a nd E thics

Chapter 1 2: P rognostication
62
Chapter 1 3: E nd-of-Life C are
65
PAGE
Chapter 1 4: E nd-of-Life C are in ICU
69
Chapter 1 5: E thics in P alliative C are
74
87
Appendix 1 : M odified C harlson C o-Morbidity Index f or E SRF
89
Appendix 2 : B ode Index f or C OPD
References
90
Appendix 3 : P alliative P rognostic S core f or C ancer
91
Appendix 4 : L ist o f A bbreviations
92
Appendix 5 : L ist o f P alliative C are S ervices & H ospices in M alaysia
94
MESSAGE FROM PRESIDENT OF

COLLEGE OF PHYSICIANS,
ACADEMY OF MEDICINE, MALAYSIA.
DR. G.R. LETCHUMAN RAMANATHAN
I would like to thank the authors for this opportunity to pen a few lines
in t his m uch-awaited h andbook.
Some of our patients may have a medical condition that may limit the
expected average life span of that individual. Doctors should help such patients
in the preparation for end-of-life care which include what kind of therapy,
where and with whom one wishes to be with at the last moments. This
preparation may allow one from not looking at death purely as a tragedy but
perhaps a s p art o f a p rocess t hat c elebrates t he p ersons life.
Before we can do so, we need to be clear in our minds, our goals in
treating patients and perhaps come up with some guidelines that all of us are
comfortable with. As young doctors, we may feel that we can do the impossible
to save a patients life. However, as we mature, we may realize that it is not just
delaying death at that moment that is important but about having a life after
the treatment i.e. to be able to communicate with fellow beings and enjoy the
beauty around us. When a doctor intubates or does some invasive investigation
or prescribes some medication that adds adverse events without increasing a
period of meaningful life, then, it may be considered as harming the patient.
This is especially so when available medical knowledge does not offer any
therapy t hat w ill improve o utcomes t hat a re important t o u s a s h umans.
Frequently, the above therapies are instituted because doctors are
uncomfortable in bringing up issues of palliation with patients or their relatives.
Then we torment ourselves with feelings of helplessness when there is
unavailability of ventilators and ICU beds for some patients whom we know will
benefit from such care. Simply giving therapy which is limited overall would not
be ideal as it may impinge on the rights and needs of others and may not be fair
to t he p atient h im o r h erself. T his is a u niversal c ommon p roblem in h ospitals a ll
over t he w orld.
All heath care personnel should know that conservative management or
palliative care is not equal to no management or passive management. It is

active management that is appropriate to relieve symptoms and provide

comfort whether as inpatient or outpatient basis. We should equip ourselves
with communication skills to be able to speak to patients about end-of-life
issues early when the patient is still very much lucid. We should have the
current k nowledge o f a vailable t herapies a nd o ptions f or a p articular c ondition
its benefits and its side effects. These should be made known to the patient in a
clear and understandable manner. One could also add your recommendation on
appropriate therapy available at your center. When this is done early, the
patient would have the option of seeking a second opinion and then get back to
you on her or his wishes. Based on the patients wishes, a plan could be set up.
Humans f ear t he u nknown. O nce w e k now w hat t o e xpect, a nxiety levels d rop.
At the College of Physicians, we felt that the medical fraternity in our
country needs to come up with some guidelines to help doctors help patients
appropriately. The authors of this handbook, led by Dr Richard Lim, answered
that need in a short period of time. This is just the beginning. As end-of-life
issues involve many stakeholders, we believe this handbook and our annual
scientific meeting with the similar theme this year will initiate the much-needed
deliberations among all to come up with comprehensive and acceptable
solutions f or o ur n ation.

Dr G R L etchuman R amanathan

10
MESSAGE FROM NATIONAL ADVISOR

FOR PALLIATIVE MEDICINE, MINISTRY
OF HEALTH, MALAYSIA
DR. RICHARD B.L.LIM
The palliative care movement in Malaysia, was first initiated in the early
1990s with volunteer services developing from non-governmental bodies such
as Hospis Malaysia and the National Cancer Society in Penang. Almost a quarter
of a century later, the work, which was once thought of as being a form of part-
time voluntary medicine, is now steadily moving forward, transforming into a
fulltime, professional, evidence-based medical specialty. As a medical specialty,
we are one of the youngest at present in the College of Physicians, where it was
only o fficially r ecognised b y t he M inistry o f H ealth in 2 005.
Although palliative medicine is a young medical specialty, it is indeed
recognized worldwide as an area of great relevance and need. In Malaysia, it is
estimated that every year at least 32,000 people die from conditions that
typically require palliative care in the months and weeks before death. It would
be safe to say that all clinicians would have come across patients requiring
palliative care at some point. Therefore, all clinicians should be equipped with
basic knowledge on how to relieve common symptoms such as pain, dyspnoea
and nausea as well as how to communicate important issues with patients and
families. Clinicians should also know how to provide appropriate care at the
end-of-life. The duty to relieve suffering is a responsibility of every healthcare
provider and the first step in fulfilling this duty is to be able to recognize the
needs.
I sincerely hope that clinicians from all fields may benefit from this
Handbook of Palliative Medicine in Malaysia which was intended to provide
basic and concise information on how to manage patients facing problems
associated with life-limiting illnesses. I also hope that through this, many more
clinicians will recognize the need to develop and strengthen palliative care
services in the country. I would like to extend my sincere gratitude to all the
authors and those who have contributed to this handbook. I would also like to
thank Dr. G.R. Letchuman Ramanathan and the College of Physicians, for their
support a nd interest t owards p alliative m edicine a nd e nd-of-life c are.

Dr. R ichard B .L. L im

11
PALLIATIVE CARE: DEFINITION AND

CONCEPT
DR. RICHARD LIM BOON LEONG, MBBS(UM), MRCP(UK)
WHAT IS PALLIATIVE CARE?

Palliative c are f or a dults is d efined a s:
An approach that improves the quality of life of patients and their families
facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and
impeccable assessment and treatment of pain and other problems, physical,
psychosocial a nd s piritual. P alliative c are:
provides r elief f rom p ain a nd o ther d istressing s ymptoms;

affirms life a nd r egards d ying a s a n ormal p rocess;
intends n either t o h asten o r p ostpone d eath;
integrates t he p sychological a nd s piritual a spects o f p atient c are;
offers a support system to help patients live as actively as possible until
death;
offers a support system to help the family cope during the patients illness
and in t heir o wn b ereavement;
uses a team approach to address the needs of patients and their families,
including b ereavement c ounselling, if indicated;
will enhance quality of life, and may also positively influence the course of
illness;
is applicable early in the course of illness, in conjunction with other
therapies that are intended to prolong life, such as chemotherapy or
radiation therapy, and includes those investigations needed to better
understand a nd m anage d istressing c linical c omplications.
World H ealth O rganisation (2002)
This is the most appropriate and widely accepted definition of palliative care
and is a pplicable t ill t oday.

12
PALLIATIVE CARE: DEFINITION AND CONCEPT
IS PALLIATIVE CARE ACTIVE MEDICINE?

Many people misunderstand the term palliative care as a term to
suggest Nothing can be done as patients who require palliative care all have
life-limiting illnesses for which there is no cure. This is an absolute
misconception a nd t here is n ever a t ime w hen n othing c an b e d one.
Although patients may not have the possibility of cure, there is still so
much that can be done to ensure that life goes on and that there is support for
them to live out their lives until the very end. This can only be achieved through
the active process of communicating, taking a history of what distresses the
patient, performing clinical examinations to interpret the signs of the distress
and performing relevant investigations that help one understand better the
underlying process of the distress. Only then can we relieve suffering and
distress through good communication skills, prescribing appropriate
medications, applying therapeutic procedures and addressing non-physical
issues t hrough p sychosocial a nd s piritual interventions.
So palliative care is not just about holding someones hand and looking sad. It is
active medicine that requires knowledge, skill, competence and above all,
compassion.
IS PALLIATIVE CARE ALL ABOUT DEATH AND DYING?

Everybody dies at some point. Just because palliative care focuses on
caring for patients with progressive incurable illness, naturally one may feel that
the f ocus is o n d eath a nd d ying. A lthough c aring f or p atients in t heir d ying p hase
is an important part of palliative care, the true focus of palliative care is about
LIVING!
Palliative care is an approach that respects life and aims to help
patients live their life to the fullest. By relieving physical symptoms, patients are
able to focus on other important issues such as spirituality and psychosocial
wellbeing. Also by supporting family during a time of great stress and difficulty
also aims to enable family members and loved ones to cope with grief and move
forward a fter b ereavement. S o, p alliative c are is t ruly a bout L IVING.

13
PALLIATIVE CARE: DEFINITION AND CONCEPT
WHEN AND WHERE DO PATIENTS NEED PALLIATIVE CARE?

As m entioned in t he W HO d efinition, p alliative c are is a pplicable e arly in
the c ourse o f a n illness a nd c an b e in c onjunction w ith o ther t reatments t hat a re
intended to prolong life. This is the basis of the integrated model of care where
we should realize that even though patients may still receive disease modifying
treatments, attention is still required to address distressing symptoms that may
be o ccurring e ven b efore a ll t reatment o ptions a re e xhausted.
This does not mean that all patients need to be referred to a palliative
care specialist right at the beginning of an illness as the need can vary. It does
however suggest that all clinicians should be sensitive to these needs and
understand how to address them at a basic level. Palliative care is a basic need
that everyone should have access to. Hence all clinicians should know how to
treat pain, basic symptoms, communicate bad news, listen and understand
ethical d ecision m aking in o rder t o s upport p atients w herever t hey m ay b e.
Patients should also have access to care in the place of their preference and
often this may be at home. Hence, care in the community is also a vital
component t o a c omprehensive p alliative c are s ervice.
Integrated Model of Palliative Care

Co-management with Mainstream
Disease-modifying therapy (curative,

life-prolonging or palliative in intent)
D
E
A
T
H
Palliative Care
Management
B
E
R
E
A
V
E
M
E
N
T
Palliative Care
Diagnosis
14

SECTION 1:

MANAGEMENT OF PHYSICAL
SYMPTOMS

15
CHAPTER 1: CANCER PAIN

DR CINDY TEOH CY OUN, MBBCH BAO(NUI) , MRCP(UK)
INTRODUCTION
The World Health Organization (WHO) and the International Association for the
Study of Pain have stated that Pain Relief is a Basic Human Right. Since 2008,
the Ministry of Health, Malaysia implemented pain as the fifth vital sign,
highlighting the importance of improving pain management in all MOH
hospitals.
POSSIBLE C AUSES
Somatic pain due to direct tissue damage by cancer in bone, muscle or

skin. C ommon e xamples:
o Bone m etastasis
o Malignant u lceration
Visceral pain d ue t o c ancer e nlarging in v isceral o rgans c ausing p ressure
and c ompression o f v iscera. C ommon e xamples:
o Liver m etastasis/tumour p ain
o Pancreatic t umour p ain
o Bowel o bstruction ( small o r large b owel & s tomach)
o Pelvic p ain f rom g ynaecological/urological c ancer
o Headache f rom intracranial t umour
Neuropathic p ain d ue t o c ancer d amaging o r c ompressing n erves.
Common e xamples:
o Brachial p lexopathy f rom p ancoast t umour ( pain r adiating d own
upper limb)
o Lumbosacral p lexopathy f rom large p elvic m ass ( pain r adiating
down lower limbs)
o Radicular p ain f rom s pinal m etastasis ( pain r adiating a round
trunk like a b elt/band)
o Facial p ain/headache/trigeminal n euralgia ( head a nd n eck
cancer)

16
ASSESSMENT
P P lace / S ite o f p ain ( Where is t he p ain?)

A - A ggravating f actors ( What m akes it w orse?)
I intensity ( How b ad is t he p ain? u se p ain s cale)
N Nature & Neutralizing factors (What does it feel like? & What
makes it b etter?)

Measuring intensity
o Infants a nd t oddlers: F LACC s cale
o Young c hildren ( 3-7years): W ong-Baker F aces s cale
o Older c hildren a nd a dults: V isual a nalogue s cale
Pain s cores
1-4
5-6
7-10
Pain intensity
Mild p ain
Moderate p ain
Severe p ain
FLACC S cale
Category
0
No particular
expression or
smile
Scoring
1
Occasional grimace
or frown, withdrawn,
disinterested
2
Frequent to constant
quivering chin,
clenched jaw
Legs
Normal position
or relaxed
Uneasy, restless,
tense
Kicking or legs
drawn up
Activity
Lying quietly,
normal position,
moves easily
Squirming, shifting
back and forth, tense
Arched, rigid or
jerking
Cry
No cry (awake or
asleep)
Moans or whimpers;
occasional complaint
Crying steadily,
screams or sobs,
frequent complaints
Consolability
Content, relaxed
Reassured by
occasional touching,
hugging or being
talked to, distractable
Face
17
Difficult to console
MANAGEMENT
Use the WHO analgesic ladder by selecting analgesia according to pain

intensity.
o Step 1 (mild pain) use non-opioid analgesics (Paracetamol,
NSAIDs, C OX-2 inhibitors)
o Step 2 (moderate pain) use weak opioid analgesics +/-
combination of step 1 drugs (tramadol, dihydrocodeine,
codeine)
o Step 3 (severe pain) use strong opioid analgesics (morphine,
oxycodone, f entanyl) + /- c ombination w ith s tep 1 d rugs

Mild to moderate somatic pain may respond well to NSAIDs and COX-2
inhibitors w here t here is s trong inflammatory p rocess.
Visceral p ain r esponds w ell t o o pioid a nalgesics
Neuropathic pain may respond to opioid analgesics but often only
partially a nd w ill r equire a ddition o f a djuvant a nalgesics.
Morphine is t he d rug o f f irst c hoice f or t reatment o f s evere c ancer p ain.
How t o u se m orphine:
o Titration of dose according to pain and response to morphine is
the m ain p rinciple.
o Oral r oute is t he r oute o f c hoice
o For severe cancer pain, which is persistent, morphine should be
given REGULARLY every 4 hours. In patients with renal
impairment, either reduce the dose or increase the interval
between t he d oses
o Apart from regular dosing, always prescribe PRN dose (the dose
would be the same as 4hrly dose) for additional breakthrough
pain.
o Start a t 3 -5mg 4 h ourly a nd P RN u sing a queous m orphine.
o After 24 hours calculate total morphine usage (regular doses +
additional P RN d oses)
o Divide t otal d ose b y 6 t o g et t he n ew 4 h ourly d ose
o Once pain is controlled, aqueous morphine can be changed to
Slow Release (SR) Morphine Tablets for convenience of dosing
by calculating total 24 hour dose and divide by 2 which is the
dose o f S R m orphine a nd g iven 1 2 h ourly.

18
Example: Patient on aq morphine 5mg 4hourly and takes 3 extra doses. Total 24 hour
morphine = ( 5mg x 6 ) + ( 5mg x 3 ) = 30mg + 1 5mg = 4 5mg
New 4 h ourly d ose i s 4 5/6 = 7 .5mg 4 h ourly a nd 7 .5mg P RN
If s table o n 7 .5mg 4 h ourly, c onvert t o T . S R M orphine = 4 5/2 = 2 2.5mg
Therefore, dose should be T. SR morphine 20mg BD (because SR morphine comes in 10mg
& 3 0mg t ablets)

Common a nalgesic d oses a nd s ide e ffects:
Drug
Paracetamol(pcm)
Ibuprofen
Mefenemic a cid
Diclofenac s odium
Naproxen
Meloxicam
Celecoxib
Etoricoxib
Tramadol
Dihydrocodeine
Panadeine
(codeine 8 mg +
pcm 5 00mg)
Aqueous
Morphine
Immediate r elease
(IR) O xycodone
Transdermal
fentanyl
Starting d ose
Max. d ose
STEP 1
0.5-1g T DS/QID
4g/day
200-400mg T DS
2400mg/day
250-500mg T DS

50mg T DS
200mg/day
250mg B D/TDS
1500mg/day
7.5mg O D
15mg/day
200mg O D/BD
800mg/day
90mg O D
90mg/day
50mg T DS/QID
30-60mg T DS
1-2 t ab T DS
STEP 2
400mg/day
240mg/day
8 t ab/day
STEP 3
5mg 4 h ourly ( in

elderly f rail p atient
3mg 4 -6 h ourly)

No m aximum
5mg 4 -6 h ourly
dose
(more p otent t han
morphine 1 .5x)
Should n ot b e u sed
in o pioid n ave
patients.
Lowest d ose
12mcg/h p atch
19
Side e ffects
Rare
Peptic u lcer, G I
bleed, p latelet
dysfunction,
nephrotoxicity,
cardiac e vents.
Hypertension, r enal
impairment, C VS
events
Drowsiness, n ausea,
constipation

Common: n ausea,
vomiting,
drowsiness,
constipation

Uncommon:
sweating, e uphoria,
pruritus, m yoclonus,
delirium
Managing s ide e ffects o f m orphine a nd o ther o pioids

o Constipation always prescribe prophylactic laxatives when
using r egular o pioid a nalgesia ( lactulose, b isacodyl, s enna)
o Nausea / Vomiting occurs in first 1 week after starting. Treat
with m etoclopramide 1 0mg T DS/QID
o Sedation occurs during initial dose and normally subsides
after a f ew d ays.
In renal or liver impairment, opioids should be used with caution at
smaller doses and longer dosing intervals (6-8 hourly). Fentanyl is the
safer o pioid t o u se in r enal impairment.
Opioid switching (changing from morphine to another opioid or another
route o f a dministration e g. o ral t o injection) m ay b e c onsidered if:
o Pain is n ot w ell c ontrolled d espite o ptimal t itration
o Intolerable s ide e ffects o ccur w ith m orphine
o Renal impairment d evelops
o Patient c annot s wallow o ral m edication
Common c onversion f actors f or o pioid s witching:
o 1mg IV/SC m orphine = 2 .5mg o ral m orphine
o 1mg o ral o xycodone = 1 .5mg o ral m orphine
o 25mcg/h f entanyl p atch = 7 5mg o ral m orphine/day
o 200mg t ramadol/day = 3 0-40mg o ral m orphine/day

Managing n europathic p ain
o Use a djuvant a nalgesics in c ombination w ith o pioids:

Drug
Starting d ose
Max. d ose
Amitriptylline
10-25mg O N
100mg O N
Sodium v alproate
200mg B D
1600mg/day
Gabapentin
Day 1 : 3 00mg O N
Day 2 : 3 00mg B D
Day 3 : 3 00mg T DS
75mg B D
2400mg/day
Sedation,
antimuscarinic
effects, c ardiac
arrhythmias
Fatigue, l oss o f
appetite, v omiting,
dizziness
Drowsiness
300mg B D
Drowsiness
Pregabalin
Side e ffects
20

When p ain is v ery d ifficult t o m anage, c onsider t he f ollowing:
o Review the diagnosis and cause of pain then consider treating
underlying c ause w ith a nticancer t herapies e g. R adiotherapy
o Consider o pioid s witching
o Refer to palliative care specialist / pain specialist for advanced
pain interventions.

Managing e xtremely a cute a nd s evere p ain e pisodes ( pain s core 9 -10/10
and p atient s creaming/very d istressed)
o Titrate m orphine intravenously o r s ubcutaneously f or f ast r elief
o In opioid nave patients, use IV morphine 1-2mg every 5-10
minutes
o If n o IV a ccess, u se S C m orphine 2 .5-5mg e very 1 5-20 m inutes.
o Review before each subsequent dose assessing pain score,
sedation s core a nd r espiratory r ate.
o Once pain is reduced to 50% of original pain score, stop
titration a nd t otal a mount g iven.
o Use t otal a mount a s 4 h ourly S C m orphine d ose a nd P RN d ose.
o Consider cause for acute severe pain eg. Rupture of tumour,
spinal c ord c ompression, p athological f racture
21
CHAPTER 2: RESPIRATORY SYMPTOMS

DR. CARYN KHOO SHIAO YEN, MD(DAL), ABIM(INT MED, HPM)
INTRODUCTION
Respiratory symptoms are common in advanced illnesses and may be due to a
variety o f c auses, w hich could be specific to the respiratory system or secondary
to systemic illnesses such as cardiac disease or metabolic abnormalities. Hence,
when faced with such symptoms, a thorough clinical assessment, complete with
a good history and physical examination is necessary. Radiological and blood
investigations, m ay a lso b e e xtremely h elpful in identifying p otentially r eversible
conditions. Therefore, even in patients where management is primarily
palliative, proper assessment and diagnosis of the underlying problem remain
essential.
BREATHLESSNESS
Dyspnoea is the subjective experience of breathing discomfort. It is a common
symptom o ccurring in v arious c onditions including c ancer, c hronic h eart d isease,
chronic lung disease and renal failure. Dyspnoea is a common trigger for panic
and anxiety and this in turn worsens the sensation of breathing discomfort
causing a v icious c ycle.
POSSIBLE C AUSES
Lung c ancer o r lung

secondaries
Pleural e ffusion
Lymphangitis c arcinomatosis
Pulmonary e mbolism
Pneumonia
Lung c ollapse o r c onsolidation
Superior V ena C ava
Obstruction

22
Cardiac f ailure / P ulmonary

oedema
COPD
Pulmonary f ibrosis
Cardiac a rrhythmias
Pericardial e ffusion
Anemia
Uremia
Respiratory m uscle w eakness
MANAGEMENT
As f ar a s p ossible t reat t he u nderlying c ause if it is r eversible:
Underlying c ause
Treatment
Pleural e ffusion
Thoracocentesis + /- p leurodesis
Pneumonia
Antibiotics
Bronchospasm
Nebulised b ronchodilators a nd
corticosteroids
Cardiac f ailure
Diuretics
Anemia
Blood t ransfusion
Superior V ena C ava O bstruction
Corticosteroids + R adiotherapy if d ue
to m alignancy
Symptomatic management of breathlessness if unable to reverse

underlying c ause:
o Opioid therapy: Morphine and other opioids are effective in
relieving dsypnoea by reducing the sensation of air hunger.
Generally, a lower dose of opioid is required to relieve
dyspnoea than is needed to relieve pain. If opioid nave, start
with oral morphine 2mg PRN and escalate as needed. If
dyspnoea is continuous, opioids should be given around the
clock, i.e. 4 hourly or use a long-acting opioid with PRN
morphine f or b reakthrough s ymptoms.
o Benzodiazepines : Panic with hyperventilation and the fear of
suffocation may worsen breathlessness. Benzodiazepines are
useful in these cases. May start with sublingual lorazepam 0.5-
1mg P RN.

Educate p atient a nd f amily o n n on-pharmacological m easures t o r elieve
breathlessness:
o Relaxation t echniques ( reduce a nxiety a nd m uscle t ension)
o Chest p hysiotherapy ( percussion, b reathing r etraining).
o Positioning ( postural d rainage, lung e xpansion)
o Directing a ir t o t he f ace ( fan, w ide s paces, o pen w indow).
o Supplemental o xygen e specially if h ypoxic.
o Energy-conserving m easures ( pacing, leaning o n s upport)

23
Managing m alignant p leural e ffusions

o In patients with short life expectancy (< 4 weeks), simple
therapeutic thoracocentesis is preferred. Do not remove more
than 1-1.5 litres at any one time to reduce risk of re-expansion
pulmonary o edema. S top t apping if p atient d evelops c hest p ain,
cough o r i ncreased d yspnoea.
o If prognosis is > 4 weeks and effusion is massive, chest tube
drainage is preferred followed by pleurodesis once lung re-
expanded. Ultrasound guided pigtail catheter or small bore
chest tubes of 10-14F are recommended as this is safer and
better t olerated.
o Pleurodesis may be performed once lung has re-expanded and
drainage minimal. Common sclerosants include, talc slurry,
tetracycline or bleomycin. Instill pleural space with 25cc
lignocaine 1% before instilling sclerosant. If bleomycin is used,
pre-medicate with paracetamol 1g. Once sclerosant is instilled,
clamp t ube f or 1 h our. If l ung i s r e-expanded, it is n ot n ecessary
to rotate the patient. After 1 hour, unclamp the tube and allow
drainage. If fluid drainage is <250cc/24h, tube can be removed.
If drainage is still >250cc/24h, process may be repeated
considering a d ifferent s clerosant.
o For patients with persistent incomplete lung re-expansion
(trapped lung) if prognosis >4 weeks, consider referral for
thoracoscopy.
COUGH
Cough is reported in up to 50% of patients with terminal cancer and in up to
80% of patients with lung cancer, occurring as a result of mechanical and
chemical irritation of receptors in the respiratory tracts. The cough reflex
depends on afferent nerve input to the medulla and efferents to the respiratory
muscles.
POSSIBLE C AUSES
The c auses a re s imilar t o t hose c ausing b reathlessness.

24
MANAGEMENT
Similar t o b reathlessness, r eversible c auses s hould b e t reated.

Productive/wet c ough ( aim is t o p romote m ucus c learance)
o Nebulised s odium c hloride 0 .9% 2 .5 m l Q ID a nd P RN.
o Bromhexine 8 mg o rally T DS
o N-acetylcysteine 2 00mg B D-TDS
o Chest physiotherapy including vibration, percussiong and
postural d rainage.

Dry c ough ( aim is t o s uppress c ough)
o Lozenges or sweet syrups to coat the throat and function as a
protective b arrier t o t he c ough r eceptors.
o Diphenhydramine ( Benadryl) 2 0mg/10ml P RN u p t o 4 h ourly.
o Opioids are potent cough suppressants and may be used at low
doses f or r efractory c ough ( Aq. M orphine 2 -5mg 4 -6 h ourly)

Dying patients and those too weak to cough should be treated with
antimuscarinics ( to d ry u p t he s ecretions) a nd c ough s uppressants.
o Hyoscine butylbromide (Buscopan) 20mg subcutaneous TDS to
start, and may be titrated up to 120mg/day. Oral Buscopan has
low b ioavailability a nd c annot b e u sed f or s ecretions.
o Glycopyrrolate 0.2mg subcutaneous is a more potent agent
than B uscopan a nd m ay b e g iven e very 4 h ours.
HICCUP
POSSIBLE C AUSES
Via vagus nerve - gastric distension, gastritis, GERD, hepatic tumors,

ascites/abdominal d istension/intestinal o bstruction
Via phrenic nerve - diaphragmatic irritation, intracranial tumors (especially
brainstem lesions), leptomeningeal d isease, t raumatic b rain i njury, s troke.
Systemic - renal failure, electrolyte imbalance (hyponatraemia,
hypokalaemia, h ypocalcaemia), c orticosteroids.

25

MANAGEMENT

Pharyngeal stimulation various remedies have been proposed, including
eating granulated sugar, sipping cold water, applying pressure to the soft
palate w ith a n inverted s poon, V alsalva m anoeuver.
Reduce g astric d istension
o Pro-kinetics m etoclopramide, d omperidone, e rthromycin.
o Encourage s mall, f requent m eals.
Relax d iaphragmatic m uscle - b aclofen
Suppress c entral h iccup r eflex haloperidol, c hlorpromazine, p henytoin.

26
CHAPTER 3: GASTRO-INTESTINAL
SYMPTOMS
DR. AARON HIEW WI HAN, MD(UKM), MRCP(UK)
INTRODUCTION
For the patient who is already very distressed with pain and breathlessness,
additional symptoms such as nausea, vomiting and constipation can be a tipping
point which causes ultimate misery for a patient. Clinicians must therefore
never forget to address simple issues such as bowel habits and appetite which
for p atients a re o f p aramount importance.
NAUSEA & VOMITING

POSSIBLE C AUSES
Mechanical
Gastric s tasis
Gastritis / g astric irritation
Constipation
Gastric o utlet o bstruction
Bowel o bstruction
Squashed s tomach d ue t o
gross a scites o r h epatomegaly
Severe c ough

Systemic
Drugs e g. O pioid,
Chemotherapy
Hypercalcaemia
Uraemia
Sepsis
Raised ICP ( brain m etastasis)
Severe P ain
Fear / A nxiety
Unpleasant t aste/smell

ASSESSMENT
Comprehensive a ssessment is n ecessary a s c auses m ay b e m ulti-factorial.
History
o
o
o
o
o

Vomiting i n r elation t o o ral i ntake is t his m echanical?

Recent c hange in b owel h abits c onstipation / o bstruction?
Fever, s ymptoms o f infection?
Headache, n eurological s ymptoms r aised ICP?
Drug h istory o pioids, c hemo, d igoxin, a ntibiotics, N SAIDs

27
CHAPTER 3: G.I. SYMPTOMS
Physical E xamination
o Dehydrated a nd lethargic u raemia, h ypercalcaemia, s epsis
o Abdominal d istension, o rganomegaly, a scites
o Indentable f aecal m asses s evere c onstipation
o Papilloedema o r f ocal n eurology b rain m etastasis
Investigations
o Renal p rofile
o Serum c alcium
o Urinalysis
o Abdominal x ray c onstipation v s o bstruction
o CT b rain / a bdomen d epending o n p ossible d iagnosis
MANAGEMENT
Correct a ny r eversible c auses

Stop m edications t hat m ight c ontribute t o n ausea a nd v omiting
Consider surgical interventions for mechanical obstruction (stenting,
bypass, s toma)
IV Dexamethasone 8-16mg daily for brain metastasis. Consider
radiotherapy.
IV B isphosphonate a nd h ydration f or h ypercalcaemia.
If not possible to correct underlying cause, relieve symptoms with anti-
emetics b y IV o r s ubcutaneous r oute:

Anti-emetic
IV/SC m etoclopramide
10-20mg T DS/QID
SC h aloperidol 1 -3mg O D
5-HT3 a ntagonist
(granisetron,
ondansetron)
IV/SC P romethazine
12.5-50mg T DS

Role
Can b e u sed in m ost c onditions p articularly
gastroparesis a nd p artial o bstruction. A void in
complete b owel o bstruction.
Acts o n c entral d opamine r eceptors. U seful in
nd
systemic c auses a nd 2 line t o
metoclopramide
Useful m ainly f or c hemotherapy induced
nausea/vomiting. M ay w orsen c onstipation.
rd
Consider a s 3 line w hen m etoclopramide a nd

haloperidol n ot e ffective.

28
Non-Pharmacological m easures
o Avoid o r limit f oods t hat m ight t rigger n ausea a nd v omitting
o Take s mall, f requent m eals
o Sweets o r c andies m ight b e h elpful
o Sit u pright a fter m eals o r w ith h ead e levated
o Optimize o ral h ygiene
CONSTIPATION
POSSIBLE C AUSES
General d ebility
Poor o ral intake
Dehydration
Inactivity
Weakness
Unfamiliar t oilet
arrangements
Specific c auses
Hypercalcaemia
Bowel
obstruction
Hypokalaemia
Spinal c ord
compression
Visceral
neuropathy
Drugs
Opioids
Antimuscarinics
Tricyclic
antidepressants
Chemotherapy
NSAIDS
Haematinics
ASSESSMENT
Always a ssess f requency, a mount a nd c onsistency o f s tools.

Digital r ectal e xamination t o a ssess impacted f aeces in r ectum.
Abdominal x -ray t o look f or impacted f aeces.
MANAGEMENT
Goal is t o a chieve b owel m ovement o nce d aily, n ormal a mount a nd s oft

but f ormed s tool.
Stimulant laxatives
o Bisacodyl ( dulcolax) 5 -10mg d aily-TDS
o Senna ( senokot) 1 5-30mg d aily-TDS
Osmotic laxatives
o Lactulose 1 0-20mls d aily-TDS
o Macrogol ( forlax, m ovicol) 1 -3 s achets d aily-TDS
o Sodium p hosphate ( fleet) 3 0mls P RN if s evere c onstipation
Lubricant s oftner
o Liquid p araffin
29
Avoid b ulk f orming laxatives c ontaining f ibre w hich m ay w orsen

constipation i n d ebilitated p atients.
Combination o f laxatives m ay b e u sed a nd b y r ectal r oute a s n eeded.
Encourage f luid intake a nd m obilise p atient if p ossible.
Always a nticipate o pioid induced c onstipation a nd p rescribe laxatives
prophylactically.
DIARRHOEA
POSSIBLE C AUSES
Laxative o verdose
Drugs a ntibiotics, c hemo,
metformin, T yrosine K inase
Inhibitors
Diet / E nteral f eeding
Overflow d ue t o c onstipation
Anxiety
Gastroenteritis
Irritable b owel s yndrome
Radiation e nteritis
Ileocolic f istula
C. d ifficile d iarrhoea
Carcinoid s yndrome
Malabsorption / C holegenic
Hyperthyroidism
Visceral n europathy

MANAGEMENT
Review d iet a nd m edications.

Ensure a dequate h ydration a nd e lectrolyte b alance.
For C . d ifficile d iarrhoea, s top c ausative a ntibiotic if p ossible a nd t reat
with m etronidazole.
For o verflow d iarrhoea, c onfirm w ith a bdominal x -ray, t hen t reat
constipation.

Consider a nti-diarrhoeal d rugs f or s ymptom r elief
o T. L omotil 1 -2tab T DS/QID
o T. L operamide 2 mg B D/PRN ( more p otent t han lomotil)
o For s evere p ersistent s ecretory d iarrhoea, S C o ctreotide 3 00-
1200 m cg/24h m ay b e h elpful.

30
ANOREXIA
POSSIBLE C AUSES
Nausea / v omiting
Altered t aste d ue t o c andidiasis, d ry m outh, d rugs
Cancer r elated a norexia-cachexia s yndrome
Depression
Squashed S tomach S yndrome d ue t o h epatomegaly o r a scites
MANAGEMENT
Non-pharmacological t reatment
o Identify c oncerns p atient o r f amilys
o Counsel p atient a nd f amily o n d isease p rocess a nd r elationship
with a norexia
o Advise s mall m eals o n s mall p late, f oods w ith s trong f lavour
(sweet o r s avoury) a nd e xtreme t emperatures ( hot o r c old)
o Reduce m edications c ausing d ry m outh a nd n ausea if p ossible.
Pharmacological t reatment
o Treat o ral t hrush if indicated w ith s ingle d ose T . F luconazole
and r egular S y. N ystatin
o Treat d epression m irtazepine h as a dditional s ide e ffect o f
increasing a ppetite t hat m ay b e b eneficial.
o T. M etoclopramide 1 0-20mg T DS/QID f or s quashed s tomach.
o Appetite s timulants s hould b e c onsidered a s a t ime-limited t rial
and t o s top if n o b enefit a fter 1 -2 w eeks. T his includes:
T. D examethasone
T. P rednisolone
T. M egesterol a cetate
2-4mg O D
15-30mg O D
80-160mg O D
INTESTINAL OBSTRUCTION
POSSIBLE C AUSES
Malignant b owel o bstruction

Benign a dhesions
Severe c onstipation
31
Severe ileus / p seudo-

obstruction
Strangulated h ernia
ASSESSMENT
A good history and review of prior imaging results may help to

determine if c ause is m alignant o r b enign.
Clinical f eatures d epend o n t he level / s ite o f o bstruction
Upper b owel o bstruction

Vomiting d evelops e arly
bilious a nd u ndigested f ood
particles
Upper a bdominal d istension
Mays s till p ass r esidual s tool
and f latus
Upper a bdominal p ain
Lower / large b owel o bstruction

Vomiting d evelops l ater
faeculant
Generalised a bdominal
distension
Absolute c onstipation n o
stool o r f latus p assed
Generalised a bdominal p ain
CT abdomen has most value as it may provide information on level and

nature o f o bstruction.
Gastrograffin s tudies m ay h elp t o p lan m anagement.
MANAGEMENT
Goals is to relieve nausea/vomiting, reduce pain and allow oral intake

where p ossible.
Surgical intervention should be considered if patients general
condition is g ood a nd p rognosis > 4 weeks.
Absolute c ontraindication t o s urgery:
o Recent laparotomy, s howing inoperable a dvance d isease.
o Carcinomatus peritonei demonstrated radiologically with
contrast s tudy s howing s evere m otility p roblem.
o Diffuse p alpable intra-abdominal m asses.
o Massive a scites, w hich r apidly r ecurs a fter d rainage.
Endoscopic stenting for partially obstructed proximal duodenal lesions
and large b owel lesions.
Where interventions a re n ot p ossible, c onservative m easures i nclude:
o SC m orphine o r T D f entanyl f or p ain
o Reduce intestinal secretion with SC buscopan (60-240mg/24h),
SC o ctreotide ( 300-900mcg/24h) o r S C r anitidine ( 200mg/24h)
o IV d examethasone 8 -16mg d aily m ay r elieve o bstruction
o SC h aloperidol 1 -3mg/24 t o r educe n ausea
o Consider N G t ube o r g astrostomy f or d ecompressing s tomach.
o SC h ydration 1 -2 p ints N S o r D 5% in 2 4h if n eeded.
32
CHAPTER 4: NEUROLOGICAL SYMPTOMS

DR. SHERIZA IZWA ZAINUDDIN, MBBS, MMED(INT MED)
DELIRIUM
INTRODUCTION
Acute confusional state, which is a result of mental clouding, is common in
people who are dying. If irreversible, it may be an indication of impending death
and c an b e m ost d istressing f or p atients, f amily a nd s taffs.
POSSIBLE C AUSES
There are often multiple organic causes but in up to 50% of cases, specific
causes a re n ot f ound, d espite i nvestigations.
Infections
Organ f ailure ( liver / r enal)
and u nderlying m edical
conditions
Drugs
- Sedatives
- Anticholinergics
- Opioids
- Benzodiazepine
- Steroids
Metabolic d isturbances
- Dehydration
- Hypercalceamia
- Hyponatraemia
- Hypoglycaemia
Hypoxia
Cerebral m etastases
Cerebral h emorrhage
Epilepsy p ost-ictal

Predisposing / P recipitating / A ggravating f actors:
Dementia a nd C NS immaturity
Pain
Fatigue
Urinary r etention / C onstipation
Unfamiliar e xcessive s timuli
Change o f e nvironment

ASSESSMENT
Clinical p resentation is t ypically a brupt in o nset w ith impairment o f

consciousness a nd f luctuating s ymptoms ( sundowner e ffect).
33
Symptoms include:
Disorientation
Fear a nd d ysphoria
Memory impairment m ainly
short-term
Hyperactive(agitated) o r
hypoactive(lethargic) b ut
usually m ixed h yperactive a nd
hypoactive m otor a ctivity
Reduced a ttention s pan t o

external s timuli
Reversal o f s leep-wake c ycle
Perceptual d isturbances s uch
as h allucinations, illusions
Disorganized t hinking s uch a s
paranoia
Confusion A ssessment M ethod ( CAM) f or s creening:

o Acute Change From Baseline - fluctuation of symptoms during
the d ay
o Inattention d ifficulty f ocusing, e asily d istracted
o Disorganised thinking incoherence, rambling, irrelevant
conversation, i llogical flow o f ideas
o Altered level of consciousness any state other than alert and
calm
(Diagnosis of Delirium requires prescence of feature 1 and 2 as well as
one o f t he latter 2 f eatures.
MANAGEMENT
Treat t he u nderlying o rganic c auses if identifiable a nd t reatable

Treat fever, hypoxia, dehydration, constipation, fear and anxiety and
pain if p ossible
Ensure there is safe and secure environment have adequate staffing,
remove p otential d angerous o bjects, ideally h ave m attress o n t he f loor
Prevent s ensory o verstimulation
Psychological interventions
o Reassurance
o Orientating a ids s uch a s c lock, p resence o f s upportive f amily
o Emotional s upport
o Cognitive strategies such as validation and repetition during
lucid p eriods
Antipsychotics m edications ( in c ombination w ith a bove m easures):
o Haloperidol is t he d rug o f c hoice.
o Initial d ose 0 .5-1.5mg P O o r S C a t n ight
o If a cute s evere d elirium 0 .5-1mg S C e very 1 -2 h ours P RN
34
Usually dose to settle patient < 5mg/24h but may be used up to

maximum o f 2 0mg/24h ( risk o f e xtrayramidal s ymptoms)
Other atypical antipsychotics may also be used if available including
Risperidone, O lanzapine, Q uetiapine ( less e xtrapyramidal e ffects)
Sedatives (should not be used alone in most cases of delirium as they
may aggravate symptoms particularly if inadequate doses are used, so
use w ith a n a ntipsychotic)
o SC M idazolam 2 .5-5mg
o T. L orazepam 0 .5-1mg P O o r S ublingually ( use o ral t ablet)
o
DISORDERS OF SLEEP AND WAKEFULNESS (INSOMNIA)

INTRODUCTION
Sleep is a physiological need that should not be taken for granted. Sleep
deprivation leads to many problems in the medically ill including fatigue,
daytime somnolence, mood disorders and demoralisation. Sleep is therefore an
important a spect o f g ood o verall s ymptom m anagement.

POSSIBLE C AUSES

Uncontrolled p hysical s ymptoms:
Drugs:
Pain
Corticosteroids
Dyspnoea
Bronchodilators
Cough
Caffeine
Nausea & v omiting
Methylphenidate ( stimulant)
Delirium
Beta B lockers ( bad d reams)
Bowel & b ladder s ymptoms
Diuretics

Alcohol
Unmet p sychological issues:

Substance
w ithdrawal:
Depression
Anxiety
Benzodiazepines
Fear o f d ying in s leep
Alcohol

Tobacco
Environmental c hanges:
Admission t o h ospital
Disturbance b y s taff o r f amily

35
MANAGEMENT
Address s ymptom c ontrol o f a bove ( pain, d yspnoea, c ough e tc)

Establish g ood s leep h ygiene
o Regular b edtimes
o Minimize d aytime n apping
o Reduce e vening s timulants e g. C affeine
o Comfortable b edding
o Comfortable t emperature
Relaxation t echniques e g. M usic, m editation, m assage
Drug t herapy:
o Anxiolytics eg. Lorazepam 0.5-1mg, diazepam 5-10mg (esp. for
withdrawal), z olpidem 5 -10mg
o Sedative a ntidepressant e g. A mitriptyline, m irtazepine
o Sedating a ntipsychotics e g. H aloperidol, q uetiepine
SPINAL CORD COMPRESSION

INTRODUCTION
Occurs in 3-5% of patients with advanced cancer. Cancers of the breast,
bronchus and prostate, account for >60% of cases. Most occur in the thorax.
There is compression at more than one level in 20%. Below the level of L2
vertebra, compression is of the cauda equina (ie peripheral nerves) and not the
spinal c ord.

CLINICAL P RESENTATION

Symptoms:
o Pain

>90%
o Weakness

>75%
o Sensory level

>50%
o Sphincter d ysfunction
>40%
Pain often predates other symptoms and signs of cord compression by
several w eeks o r m onths. P ain m ay b e c aused b y:
o Vertebral m etastasis
o Root c ompression ( radicular p ain)
o Cord c ompression ( funicular p ain)
o Muscle s pasm

36

ASSESSMENT
History a nd c linical f indings w ith h igh index o f s uspicion
o any cancer patient presenting with numbness, weakness or
urinary r etention s hould b e t aken s eriously
X-rays of spine shows vertebral metastasis and/or collapse at the
appropriate level in 8 0%
Bone scans are sensitive to detect bone metastasis but not specific to
confirm s pinal c ord c ompression.
MRI is the investigation of choice, CT with myelography may be helpful
if M RI is n ot a vailable.
Even w ithout a n M RI, it is p ossible t o c orrelate c linical f indings ( ie. L evel
of neurology and pain) with other radiological findings which may
provide s ufficient e vidence t o c onfirm c ord c ompression.

MANAGEMENT
Although often insidious in onset, spinal cord compression should be
treated a s a n e mergency.
Dexamethasone, dose used varies greatly, consider 16-32mg PO daily for
5-7 d ays t hen r educe t he d ose g radually o ver 2 -3 w eeks
Urgent r adiation t herapy, c oncurrently
Decompression s urgery, if t here is:
o deterioration d espite r adiotherapy a nd d examethasone
o a s olitary v ertebral m etastasis
o doubt a bout t he d iagnosis

Patients with paraparesis do better than those who are totally
paraplegic. Loss of sphincter function and rapid onset of complete
paraplegia ( <48h) is a b ad p rognostic s ign.
37
CHAPTER 5: ORAL CARE

DR. HARRE HAREN A/L RAMASAMY @ RAJOO, MBBS, MMED(INT MED)

INTRODUCTION

Oral problems affect the majority of palliative care patients and have great
impact on the quality of life. This may often be under-estimated. Saliva with its
various components gives major protection to the tissues of the oral cavity
keeping it moist and clean, maintaining an intact mucosa. Reduction in
production of saliva and poor oral hygiene are the main etiologies contributing
to oral problems. Dry mouth may be due to mouth breathing, medications and
reduced oral intake. Chemotherapy, irradiation and local tumor invasion may
lead t o b roken m ucosa.
HALITOSIS
This is a n u npleasant o r f oul-smelling b reath, w hich is s ocially u nacceptable.
POSSIBLE C AUSES
Dry m outh
Poor o ral/dental h ygiene
Stomatitis
Infections
Tumour n ecrosis a nd s epsis
Smoking
Hepatic o r r enal f ailure
Gastro-esophageal r eflux
Diabetic k eto-acidosis
MANAGEMENT
Optimise O ral H ygiene

o regular c leaning o f t eeth a nd t ongue.
o dental f lossing ( using p referably u nwaxed f loss).
o saliva s timulant / s ubstitute, i.e. p ineapple c hunks / p ilocarpine.
o refreshing m outh w ash ( avoid a lcohol b ased m outhwash w hich m ay
lead t o w orsening m outh d ryness)
o for h eavily f urred t ongue o r n ecrotic t umors, c onsider g argling w ith
sodium b icarbonate m outhwash, c hlorhexidine 0 .2% o r p ovidone
iodine 1 % ( Betadine m outhwash)

38
Treat Infections
o oral c andidiasis
o use local o r s ystemic m etronidazole f or s uspected a naerobic
infections ( due t o n ecrotic t umour)
XEROSTOMIA (DRY MOUTH)

POSSIBLE C AUSES

Dehydration
Drugs ( antimuscarinics,
opioids, d iuretics, T CAs,
Hypercalcaemia
antihistamines)
Impaired s alivary g lands ( due
Mouth b reathing
to r adiation, s urgery, c ancer)
Oxygen t herapy
Infections
Anxiety
Alcohol
Depression
Smoking

MANAGEMENT

Non-pharmacological
o frequent s ips o f w ater o r s imple m outh s pray
o pineapple c ubes.
o artificial s aliva ( preferably w ith n eutral P H).
o petroleum-based lip b alm ( for d ry lips).
o optimize o ral h ygiene.

Pharmacological
o Pilocarpine 5mg to 10mg TDS (to use cautiously in presence of
glaucoma, d iaphoresis a nd s pecific c ardiac c onditions).
o Avoid m edications c ausing d ry m outh.
o Dry m outh c are p roducts c ontaining e nzmes t o c leanse a nd h ydrate
oral m ucosa ( Biotene, O razyme).

39
STOMATITIS

Painful inflammatory, erosive and ulcerative condition affecting the mucous
membrane lining o f t he m outh.

POSSIBLE C AUSES
Radiotherapy / C hemotherapy induced m ucositis

Infections
o Candidosis ( candidiasis)
o Herpes S implex V irus
o Apthous U lcers
Drug-induced u lceration ( antibiotics, p sychotropics, a ntihypertensives)
Neutropenia
Malnutrition
MANAGEMENT
General m easures
o maintain g ood o ral h ygiene.
o give s oft f ood
o avoid f ood t hat c an t rigger p ain, i.e. s picy a nd a cidic f ood
o consider s hort-term d enture r emoval t ill h ealing o f s tomatitis.
o consider t opical h oney.

Treat p ain
o Benzydamine o ral r inse ( difflam) 3 0-60 s econds 3 -4h
o Chlorhexidine 0.2% mouthwash for infection (use only alcohol-
free t o p revent s tinging)
o Xylocaine v iscous 1 0-15mls 4 h ourly ( rinse a nd s pit)
o Topical a pplications b onjela, o rabase, o ral a id
o Sucralfate s uspension ( muco-protective)
o If using oral Aq Morphine as systemic analgesic, hold in mouth
for 2 m inutes b efore s wallowing ( for t opical e ffect a s w ell.
o If u nable t o s wallow c onsider S C m orphine f or s ystemic
analgesia.

40
Treat s pecific infections

o HSV infection - starts with vesicles that rupture forming
irregular, bordered, small (5mm) ulcers with erythematous
margins and grey centres. Gingiva will be painful, swollen or
may bleed. Lip lesions may develop crusts. Treat with oral
Acyclovir 200mg 5 times per day for 7-10 days. (requires dose
adjustments in renal impairment). Consider IV if unable to
swallow.

o Oral candidiasis - Starts as painless white flakes or patches that
adhere firmly to buccal mucos. Manifests as white plaques on
the b uccal m ucosa o r t ongue. M ay a lso p resent a s a s mooth r ed
painful tongue or angular stomatitis. Treat with nystatin
suspension 400,000 units QID (swish and swallow after keeping
in mouth for several minutes). Consider T. Fluconazole 100mg
to 2 00mg d aily d ose f or 7 d ays o r IV if u nable t o s wallow.
41
CHAPTER 6: SKIN CARE

DR. HARRE HAREN A/L RAMASAMY@RAJOO, MBBS, MMED(INT MED)
MALIGNANT CUTANEOUS WOUNDS

INTRODUCTION
Malignant cutaneous wounds develop due to fungating ulceration of superficial
malignant lesions in the skin, breast, abdominal or chest wall as well as lymph
nodes. Problems arising from this includes pain, bleeding, infection, exudates
and m alodour leading t o p sychological d istress.

ASSESSMENT

When a ssessing a p atient w ith a m alignant w ound, a sk t he following:
About t he w ound
About t he p atient
Is it h ighly e xudative
Is it p ainful?
Is it b leeding?
How w ill t he p atient c ope a t
home?
Is it infected?
How d oes it a ffect d aily living?
Is t here m alodour?
What a re p atient/family
Does it g et s oiled b y
fears?
faeces/urine?

MANAGEMENT
Malignant wounds will not heal despite cleansing, dressing and
debridement. This should be clear to the patient and family that the
goals o f m anagement include:
o Keeping t he w ound n eat a nd c lean
o Prevent infection
o Reduce p ain
o Reduce o dour
o Reduce b leeding
Daily dressing with normal saline to irrigate and clean wound helps
reduce infection and helps patients feel dry and clean after removing
previous s oaked d ressings.
If wounds are large, irrigating in the bathroom with a shower hose with
warm w ater m ay b e m ost s uitable.

42
For large exudative wounds, gamgee pads may be used with calcium
alginate dressings. (At home a simple cheap alternative could include
disposable b aby d iapers)
Wound pain should be treated with systemic short acting opioids given
30 m inutes p rior t o d ressing. T opical lignocaine g el m ay a lso b e u seful.

Malodour m ay b e r educed b y:
o Applying topical metronidazole (T. Metronidazole 400mg may
be crushed and mixed with lignocaine gel and applied into
wound)
o Oral/IV m etronidazole if s evere
o Live-culture y oghurt t opically
o Manuka h oney t opically
o Activated charcoal (crush 2 tablets and place within a piece of
gauze t hen a pply o n t op o f t he inner layer o f d ressing)

Infection may be treated commonly with systemic antibiotics
eg. c o-amoxiclav

For b leeding w ounds:
o Initially a pply s imple d irect p ressure w ith g auze
o Topical a drenaline 1 :1000 a pllied t o g auze t opically
o Consider topical transexamic acid (may use IV solution applied
to gauze topically. Oral Transexamic acid power may also be
applied t opically)
o If p ossible r efer f or p alliative r adiotherapy t o b leeding w ound.
PRESSURE ULCERS

INTRODUCTION
Prevention is the most important approach. All patients who are increasingly
unwell and immobile should be assessed for risk of pressure sores and
preventative measures such as regular turning and use of ripple mattresses
should be applied. Sometimes however, pain may cause difficulty in moving
patients a nd p reventing p ressure s ores c an b e d ifficult.

RISK F ACTORS
Immobility
Skin f ragility
Incontinence
Anaemia
Emaciation/malnutrition
Old a ge

43
ASSESSMENT

Stage 1
Stage 2
Stage 3
Stage 4
Pressure U lcer S taging

Intact s kin w ith n on blanchable r edness o f a localized a rea u sually
over a b ony p rominence. D ark p igmented s kin m ay n ot h ave v isible
blanching: Its c olour m ay d iffer f rom s urrounding a rea.
Partial t hickness loss o f t he d ermis w hich p resents a s a s hallow o pen
ulcer w ith a r ed-pink w ound b ed w ithout s lough. It m ay a lso p resent
as a n intact o r r uptured s erum f illed b lister.
Full t hickness t issue loss. S ubcutaneous f at m ay b e v isible. M uscle,
tendon o r b one a re n ot e xposed. S lough m ay b e p resent b ut d o n ot
obscure t he d epth o f t issue loss. T here m ay b e u ndermining o r
tunnelling.
Full t hickness o f t he t issue involved w ith m uscle, t endon a nd b one
exposed. S lough a nd e schar m ay b e p resent. O ften i ncludes
undermining a nd t unneling.

MANAGEMENT
Stage 1 relieve pressure, apply barrier cream (zinc oxide ointment)
and k eep c lean w ith s aline.
Stage 2 relieve pressure, clean with saline and consider occlusive
dressing w ith d uoderm o r f ilm.
Stage 3 & 4 relieve pressure, consider wound debridement if
necessary, short term povidone iodine dressing if infected and consider
hydrogel/hydrocolloid + /- a lginate o r f oam d ressing.
Method of necrotic tissue debridement should be based on the goals of
patient, absence or presence of infection, amount of necrotic tissue
present a nd e conomic c onsideration f or t he p atient.
OEDEMA

Oedema is common in patients with advanced illnesses and is often a result of
multiple f actors including immobility, lymphatic f ailure, h ypo-albuminaemia, s alt
and water retention and disease processes such as cardiac and renal disease.
Patients a re o ften v ery c oncerned w ith o edema a s it is a n o bvious s ign indicating
that t heir b ody is u nwell.

44
POSSIBLE C AUSES

Generalised
Localised
Hypoalbuminemia
Venous o bstruction ( DVT, S VCO,
Portal v ein)
Congestive c ardiac f ailure
Lymphatic o bstruction
Renal f ailure
(malignancy, s urgery,
Drugs N SAIDS,
radiotherapy, f ilariasis)
antihypertensives, c orticosteroids

ASSESSMENT

If localised oedema, ultrasound and CT imaging may be necessary to
determine c ause o f p ossible v enous o r lymphatic o bstruction.
Assess p roblems a ssociated w ith o edema:
o Tightness/heaviness o f limb
o Pain
o Impaired m obility
o Infection
o Altered b ody image

MANAGEMENT

Advise positioning for lower and upper limb oedema elevate above
level o f h eart w hen s leeping.
Refer to physiotherapist and occupational therapist for lymphatic
massage, e xercise a nd p neumatic c ompression w here a ppropriate.
Advise on skin care and hygiene to prevent infections (use protective
gloves a nd f ootwear).
Treat c ellulitis w ith a ntibiotics e g. C loxacillin, c o-amoxiclav
If f luid o verloaded, c onsider d iurectics e g. f rusemide
Specific treatment of localised lymphoedema due to tumour infiltration
or v enous c ompression
o Corticosteroids t o r educe t umour c ompression
o Radiotherapy / c hemotherapy if a ppropriate
o SC drainange if patient does not mind the procedure and
subsequent c are o f t he d rainage b ag ( may u se s toma b ag).
Consider a nticoagulation f or D VT if a ppropriate.

45
SECTION 2:

PSYCHOSOCIAL CARE,
SPIRITUAL CARE
AND
COMMUNICATION

46
CHAPTER 7: DEPRESSION
DR. SHERIZA IZWA ZAINUDDIN, MBBS, MMED(INT MED)
INTRODUCTION
In patients who are terminally ill, it is important to distinguish between clinical
depression and profound sadness. 5-10% of patients with advanced cancer have
major d epression w hile a nother 1 0-15% h ave d epressive s ymptoms a s a r eaction
to t heir c urrent illness.
ASSESSMENT
Diagnosing depression can be challenging as some symptoms of

depression such as loss of energy and poor appetite can also be due to
the underlying illness. As such, 2 core symptoms that would be most
suggestive o f d epression in t his g roup o f p atients include:
o Persistently low m ood / h opelessness ( most o f t he t ime)
o Anhedonia loss o f interest o r p leasure in life

Other s ymptoms include:
Withdrawal f rom f riends a nd
Persisting s uicidal i deation
family
Decreased a ttention a nd
concentration
Morbid g uilt a nd s hame
Worthlessness a nd low s elf
Cognitive slowing / impaired
esteem
memory
Ruminative n egative t houghts
Indecisiveness
Request f or p hysician a ssisted
Feeling o f u nreality
euthanasia
Brooding, s elf-pity
Screening for depression can be done using the HADS (Hospital Anxiety
& Depression Scale) or may be as simple as using the single item
depression s creen:
o Single-item Have you been depressed most of the time for
the past two weeks? or Are you depressed? (an answer yes
is a p ositive s creen)

Risk f actors f or d epression include:
o Inadequate s ymptom c ontrol
o Poor q uality o f life

47
CHAPTER 7: DEPRESSION
o
o
o
o
o
o
o
Lack o f s ocial s upport

Past a nd/or f amily h istory o f d epression
Older a ge
Misinformed p rognosis
Drugs ( steroids, c ytotoxics, n euroleptics, s edatives)
Immobility
Advanced m alignant d isease
MANAGEMENT
All patients with positive depressive screen should be considered for

psychiatric r eferral in v iew o f p ossible m ajor d epression.
Mild t o m oderate d epression

o Support, empathy, clarification of stressors or precipitators,
explanation, c ognitive t herapy, s ymptomatic r elief

Severe d epression
o Supportive p sychotherapy p lus d rug t herapy
o Drug therapy (antidepressants are effective in 50 to 70% of
cases)
o SSRI e g. e scitalopram, s etraline
o Mirtazepine m ay h elp s leep a nd improve a ppetite
o Psychostimulants eg. Methylphenidate 2.5-5mg BD and titrate
to e ffect m ax 2 0mg B D.

(Note: All antidepressants typically take several weeks to have
effect. In cases where prognosis is expected to be short, <2
months, methylphenidate may be useful as the onset of action
is f aster. T his indication h owever is o ff-label)
48
CHAPTER 8: SPIRITUAL CARE

DR. DIANA KATIMAN , MBBCH BAO(NUI), MMED(INT MED)
INTRODUCTION

Spiritual care is one of the core aspects of palliative care. Spirituality not only
relates to ones faith, but it is to do with how we live, what we treasure and
value, and peace of mind. Religiosity is the manifested actions of ones
spirituality o r t he p racticed r ituals o f a n o rganized b elief.

When dealing with patients (and ourselves), we have to remember that all
patients h ave s piritual n eeds b ut o nly s ome w ill h ave r eligious n eeds.

SPIRITUAL D ISTRESS

When a person experiences a life crisis, they will look to their spiritual values,
beliefs, attitudes or religious practices to make sense of it. If these do not
enable t hem t o c ope w ith t he c risis, t hen t hey m ay e xperience s piritual d istress.
Expressions o f s piritual d istress include:
fear a bout t he f uture, a bout d ying a nd w hat h appens a fter d eath
loss o f identity o r r oles ( parenthood, w ork e tc)
helplessness a nd loss o f c ontrol o ver w hat is h appening
anxiety a bout r elationships, b ody image o r s exuality
suffering e xcessively f rom p hysical s ymptoms, e specially p ain
anger ( towards G od/self/family/friends/doctors) Why m e?
guilt o r s hame
hopelessness, d espair, f eeling a lone o r u nloved
exploration o f m eaning a nd p urpose o f t heir life

DEALING W ITH S PIRITUAL D ISTRESS
First, we must be comfortable with our own spirituality and/or

religiosity, and be clear to some extent, on our own spiritual issues
listed a bove, if a ny.

49
CHAPTER 8: SPIRITUAL CARE
When patients are ready to open up on the subject, our aim is to help
the person towards some resolution and understanding. Accept that
there is u nlikely t o b e a s pecific a nswer it is OK n ot t o k now.

Listen attentively and be prepared to face uncertainties just by being
there you can help the patient to make connections and embark on
their o wn s earch f or m eaning.

Doing a Life review exercise is an example of how we can help the
patient to come to terms with who they are, what they have become,
their achievements and their regrets, their unfinished businesses. Once
we manage to put the past into perspectives, it will be a lot easier to
help p atients a ddress w hat i s t o c ome a nd h ow t hey w ould f ace i t.

Some patients may want to practice certain religious rituals to help
them deal with their spiritual distress. If you feel you are out of your
depth in dealing with certain issues with their spiritual and/or religious
needs, offer a particular group or person such as an
imam/monk/chaplain t o b e t here f or t he p atients.

Helping patients deal with their spirituality may be emotionally draining
for you. Make sure you are able to detach yourself from the emotions
with s upport f rom f amily a nd f riends o r d oing s omething y ou e njoy.
50
CHAPTER 9: RELIGIOUS DIVERSITY

DR. DIANA KATIMAN, MBBCH BAO(NUI) , MMED(INT MED)
INTRODUCTION
In caring for palliative care patients in multicultural-and-multireligious Malaysia,
it is useful for us to have an idea on the concepts of life and death of the major
religions in our nation. However, it is important to note, that even when
patients identify with a religious group, they are individuals in their own
devoutness a nd e xpression t o p ractice t heir b elief.
Do not assume (by their name or appearance). Always check with the patient
(and/or f amily) c oncerning t heir b eliefs a nd p ractices. W hen in d oubt, f ollow t he
more o rthodox p rocedures.
ISLAM
CONCEPT O F L IFE & D EATH
Muslims believe that men are created to serve The Creator (Allah). The
practicing Muslims will align their thoughts, speech and actions according to
what will please Allah. The acts of worship are not confined to the religious
rituals of prayers, fasting, performing haj and paying alms, but living a life like
how T he C reator w anted t hem t o live, is h ow p racticing M uslims serve A llah.
Muslims believe that the soul exist in a continuum from one world to
another world-and hence, life after death. In the present world, Muslims
believe that all their thoughts, speech and actions are accounted for and that
the a ccumulated g ood d eeds m inus t heir b ad d eeds w ill r esult in w here t hey w ill
be in t he e ternal w orld a fter d eath.
CARE O F T HE D YING
Muslim patients will want to observe all compulsory religious rituals as
best as they could (with adaptations of the rituals to their physical disabilities,
for example, an ill Muslim patient is allowed to perform obligatory prayer in a
supine p osition), s o c larity o f t hought is important. T hey m ay f ear o f b ecoming

51
too drowsy on opioids, which may prevent them from observing any kind of
worship to accumulate good deeds before death. To be able to perform the
prayers, Muslim patients must cleanse themselves as best as possible. They may
need help to empty the stoma or urine drainage bags and to perform the
ablution, b efore t he p rayers.
Reading or listening to the Quran is a means to find inner peace. The
Yaasin recitation by family and friends is to facilitate the journey of the
Muslim patient, either towards recovery and health, or towards a peaceful and
easy p assing t o t he n ext w orld.
For a Muslim, the last words before he/she passes on to the next world
should be the syahadah (The declaration that there is no God but Allah). A
close family member or friend may want to be close to the patients ear to help
the patient in proclaiming the syahadah. If no family member or friend were
available during the active phase of dying, patients family would usually
appreciate a m edical s taff t o h elp t he p atient w ith t he syahadah.
PROCEDURE A T D EATH
Eyes and mouth of the Muslim patient should be closed upon death and
the body covered. The hands should be placed on the chest as if in prayers, and
when p ossible, t he b ody p ositioned t o f ace t he d irection o f t he K aaba in M ecca.
The deceased body would be cleansed by a family member or entrusted
person and shrouded in white cloths. Families and friends will then perform a
prayer for the deceased and preparations made for burial of the body within
24hours o f d eath, if p ossible.
BUDDHISM
CONCEPT O F L IFE & D EATH
For the Buddhist, human existence is essentially cyclic. Birth leads to
death, which in turn leads to rebirth, and so on. Each lifetime is merely one
stage in the journey of an individual, involving hundreds or even thousands of
rebirths (reincarnation or transmigration of the soul or samsara). In the
samaric world- view, the main reason why certain people are more fortunate
than others in this life is because of a quality that has been carried over from
their p revious life-karma.

52
For Buddhists, karma is measured by the extent to which one overcomes or fails
to overcome the enslaving vices of greed, hatred and ignorance. For those who
are advanced in the way of the Buddha, such as monks and nuns, there is a
strong possibility that their good karma at death will elevate them into the
realms of the gods, or even enable them to attain the final liberation, the
nirvana. For those who are not as wise or virtuous, the general expectation is
rebirth into t he w orld in s ome n ew f orm o r s ome o ther r ealm.
Buddhist monks tend to be more involved in the process and following
death, aiming to facilitate the journey through the process of rebirth. Prior to
death, c hantings o r m antras a re r ecited t o t he p atient, s o t hat t he f inal t houghts
of t he d ying p erson a re w holesome.
The corpse is bathed and dressed in preparation for the funeral, which
may be delayed several days to enable distant relatives and friends to attend
the c eremony. O n t he d ay o f t he f uneral, it is c ustomary t o c arry t he b ody o ut o f
the house via a special door, with the monk preceding the coffin in the funeral
procession t o t he s ound o f c heerful m usic, t o g enerate g ood k arma.
It is common practice in Buddhist culture to cremate the body although there
are e xceptions.
CHRISTIANITY
CONCEPT O F L IFE A ND D EATH
Christians believe in the concept of Trinity (The Father, The Son and
Holy S pirit). T he N ew T estament t eaches t hat t he S on is " of t he s ame s ubstance"
as the Father, meaning he is eternal, and therefore any differences that exist
between them occur within the divine unity. The belief of the crucifixion of
Jesus on the cross bearing the sins of mankind, and his subsequent resurrection
has a considerable impact on the Christian understanding of death and the
afterlife. Given the centrality of the resurrection, it is to be expected that
Christian funeral rites are dominated by the theme of Jesuss victory over death
and t he p romise it h olds f or t hose w ho d ie w ith f aith in h im.

53
Spiritual care for the dying Christian varies from church to church but
often involves prayers of comfort and appropriate scripture readings. In the
catholic t radition, t he p riest p erforms a t hreefold r itual k nown a s t he last r ites
which comprises confession of sins, anointing with oil and consumption of the
sacred h ost k nown a s v iaticum, o r f ood f or t he f inal j ourney.
Once death has occurred, there is no concern to bury quickly. In many
cases, the funeral is held after around three days. During this period, many
Christian g roups h old a s imple v igil a t w hich t he m ourners p ray b eside t he c offin
of t he d eceased e ither in a c hurch o r f uneral p arlour.
There is no prohibition in Christianity on viewing the body, and the
coffin is opened for this purpose. Occasionaly, a plain-coloured cloth known as a
pall is p laced o ver t he c offin t o s ignify e quality in d eath. T he c ross o r t he c rucifix
is a common feature on coffins and graves, linking the deceased to the belief of
the d eath o f J esus a s s aving m ankind.
HINDUISM
CONCEPT O F L IFE A ND D EATH
Hindus b elief o n t he c yclic v iew o f h uman e xistence b ased o n t he h ope
of u ltimate liberation f rom t he w heel o f r eincarnation a nd t he u nimportance o f
the p hysical b ody, w hich is t hus c remated e ach t ime.
The manner and timing of death is particularly important for Hindus. A
premature or violent passing, accompanied by vomit or urine and an anguished
facial expression is considered to be a bad death. In contrast, a good death
occurs in old age after spiritual preparation and is manifest is a peaceful
countenance.

54
Once the person passed away, it is customary in Hinduism to hold the
funeral as quickly as possible. Coins are traditionally placed in the orifices of the
body to stop the atman from escaping prematurely. Old clothes are replaced
with new garments symbolizing the need for the deceased to surrender the old,
obsolete body and dress in a new one. The eldest son is considered the chief
mourner and plays a crucial role for the following rituals for the happy release
of the deceased. Cremation is the most common means of bodily disposal in
Hinduism although there are some notable exceptions. Babies and children
under the age of reason are often buried on the basis that they are still
innocent.
55
CHAPTER 10: COMMUNICATION SKILLS

INTRODUCTION
Good communication is the key to good medical care without which it would be
impossible to provide high quality care especially in the seriously ill. Clinicians
must recognise that effective communication is part of a management plan
which is just a s important a s p rescribing m edications in t he a cutely ill.
GENERAL PRINCIPLES OF COMMUNICATION IN CLINICAL PRACTICE

A useful acronym to follow when embarking on a task in communication is the
word P REPARED.
P - P repare a nd u nderstand a ll t he u pdated information o n

p atients c ondition a nd s tatus
R - R apport. R elate t o p erson. S how e mpathy a nd c ompassion
E - E xpectations. E licit p atient a nd c aregiver e xpectations a nd
p reference f or information.
P - P rovide information in s imple c lear language.
A - A cknowledge e motions a nd c oncerns
R - R ealistic h ope
E - E ncourage q uestions
D - D ocument d iscussion in m edical r ecords
DEVELOPING RAPPORT
Having good rapport with the patient and family members cannot be over-
emphasised as a vital key to successful communication particularly when
discussing issues of end-of-life. Family members are always more receptive of
information from a doctor or a nurse who can make them feel at ease and
shows g enuine c oncern f or t he p atient.
Developing rapport is the next vital step in the communication process and
should be considered akin to a license which must be obtained before any
attempt t o p rovide information b e d one.

56
Ways t o d evelop g ood r apport:

Introduce y ourself

Know y our f acts

Listen

Show e mpathy
Openly s tate y our n ame

Explain y our r ole in t he c ase
Prepare b efore d iscussion

Inaccuracies r eflect lack o f c ompetence a nd
confidence i s l ost
Understand w here t hey a re c oming f rom

Assess insight, c oncerns a nd e xpectations ( ICE)
Use e mphatic p hrases e g. I k now t his m ust b e

very d ifficult f or y ou o r I k now y ou m ust love
him/her v ery m uch
Emphatic p hrases a re p hrases w hich s how t hat
you r ecognize t he e motion a nd u nderstand t he
reason b ehind t he e motion.
Body L anguage

Honesty

Apply a ppropriate f acial e xpressions, t one o f

voice a nd s imple g estures ( eg. t ouch) w hich a re
consistent w ith c ontext o f d iscussion.
Never t alk a bout t hings y ou a re u ncertain o f
SPECIFIC COMMUNICATION ISSUES IN PALLIATIVE CARE

BREAKING B AD N EWS
Common s cenarios:
o Informing patient/family of life-threatening diagnosis for the first
time.
o Informing family that condition of patient is worsening / not
responding t o t reatment.
o Explaining sudden acute deterioration from complications of
disease o r t reatment

57
CHAPTER 10: COMMUNICATION SKILL
6 s teps t o f ollow w hen b reaking b ad n ews:

Step 1
Ensure p rivacy a nd c onducive e nvironment

Step 2
Assess t he insight o f t he p atient/family r egarding t he issue f or
discussion

Step 3
Determine w hat t he p atient/family w ould like t o k now w ith a
warning s hot t hat t he n ews is n ot likely t o b e g ood

Step 4
Break t he b ad n ews u se s imple language

Step 5
Acknowledge r eactions a nd c oncerns. P rovide information a nd
support w ith e mphatic r esponses

Step 6
Sum u p a nd p rovide r ealistic p lan t o m ove f orward

Never a ssume w hat p atients w ant o r d o n ot w ant t o k now.

Step 3 is an important step to determine what patients want to know
and h ow m uch t hey w ant t o k now b efore p roviding information.
Never lie a nd a lways p rovide r ealistic h ope.
TALKING A BOUT P ROGNOSIS
Common s cenarios:
o Patient a sks Am I g oing t o d ie?
o Patient a sks How long d o I h ave left?

Generally when patients ask about their prognosis, there is an
underlying reason and before answering the question directly it may be
preferable t o a sk t he p atient, Tell m e w hat y our c oncerns a re? o r Tell
me w hat w orries y ou m ost? t o a llow a b etter u nderstanding o f w hy t he
question is b eing a sked.

Do n ot a nswer in t he f ollowing m anner:
o We a re a ll g oing t o d ie a s t his d oes n ot a nswer t he q uestion.
o Exact d uration e g Six m onths, 4 w eeks, 1 y ear

58
Admit that it is difficult to know precisely and then specify in terms of a

range
o Weeks t o s hort m onths ( 3-8 w eeks)
o Days t o s hort w eeks ( 1-3 w eeks)
o Months b ut p ossibly less t han 6 ( gradual d eterioration)

Consider u sing a n important d ate a s a r eference p oint ( religious f estival,
birthday, anniversary) eg. I think he would be quite unwell by the time
of h is n ext b irthday
Patients and family do not need accuracy of prognosis they merely
require a n idea o f h ow t o p lan a head.

DISCUSSING C LINICAL D ECISIONS A T T HE E ND O F L IFE
Common s cenarios
o Decisions o n r esuscitation a nd m echanical v entilation
o Decisions o n a rtificial n utrition
o Decisions o n p lace o f c are t owards t he e nd-of-life

Ideally, these discussions and decisions should have been made while
patients are still mentally competent and have a clear understanding of
the implications o f interventions t owards t he e nd o f life.
Such discussions should occur during the time of discussing poor
prognosis a nd n ot in isolation.

Useful o penings:
o Have you ever discussed with your family what you would or
would n ot w ant if y ou w ere t o b ecome v ery u nwell later o n?
o Some people feel they would prefer to be cared for at home in
their last d ays, w hat is y our o pinion o n t hat?

Discussing r esuscitation w ith f amily:
o CPR and ventilation are medical interventions whereby
decisions to intervene must be made by trained healthcare
professionals p rimarily c aring f or t he p atient.

59
Do NOT ask family members to decide on whether they would

like r esuscitation t o b e d one a s t his is a m edical d ecision.
o Discussion is mainly to inform family of why the medical team
has decided that resuscitation is not in the patients best
interest a nd f ocus is c omfort a nd d ignity.
o Family should be allowed to express their opinion and clinicians
should b e e mphatic in t heir r esponses.
o If family opinion differs, it is appropriate to suggest them to
seek a s econd o pinion f rom a c redentialed c linician.

Useful p hrases:
o You must love him/her very much and seeing him/her like this
must b e v ery p ainful f or y ou.
o I know you want the best for him/her and sometimes,
resuscitation m ay n ot b e t he b est t hing.
o What do you think he/she would want if he/she could talk
right n ow?

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CHAPTER 11: HANDLING EMOTIONS

DR. TAN SENG BENG, MBBS(UM), MRCP(UK)
INTRODUCTION

Emotions a re a c omplex p sychological s tate t hat involves 3 d istinct c omponents:
subjective e xperience ( feelings)
physiological r esponce ( mood)
behavioural o r e xpressive r esponse ( affect)

Emotions motivate one to take action; help one to survive, thrive and avoid
danger; help one to make decision. Emotional intelligence is the ability to
identify emotions in self and others; understanding emotions; using emotions in
reasoning; m anaging e motions. B asic e motions include:

anger
sadness
disgust
happiness
fear
surprise

ASSESSMENT
Allow p atient t o f reely e xpress e motions
Pay attention to emotional cues from facial expression, verbal
expression, b ody l anguage a nd p aralanguage
Explore e motions w ith q uestions s uch a s:
o Tell m e m ore a bout h ow t his m akes y ou f eel
o What w orries y ou t he m ost?
o This o bviously u psets y ou, w ould y ou like t o t ell m e m ore?
Attempt t o u nderstand t he:
o c auses a nd c onditions c ontributing t o t he e motions
o b eliefs, h opes, e xpectations o f t he p erson
o behaviour a ssociated w ith t he e motion

MANAGEMENT
Allow p atients o r f amily m embers t o e xpress t heir e motions
Allow t hem t o t alk a bout t heir e xperiences
Listen t o t heir s tories w ithout interrupting t hem

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CHAPTER 10: HANDLING EMOTIONS
Do n ot b lock t heir e xpressions b y ignoring t heir e xpressions, d eviating

away f rom t heir e xpression, e xplaining t heir s ituations o r f ocusing o n
the b iomedical a spect o f t he a ssessment.
Once w e t hink t he p erson h as e xpressed s ufficiently, w e m ay t hen
express o ur e mpathy t hrough c onfirming, a cknowledging, v alidating a nd
normalizing t heir e motions.
o Confirm t heir e motions r ather t han a ssuming o r s uggesting
clarify t heir e motions
o Acknowledge t heir e motions t alk a bout t heir e motions
o Validate t heir e motional e xpressions inform t hem it is a lright
to h ave e motions
o Normalize t heir e motional e xpressions w henever it is
appropriate a greeing w ith t hem b y c omparing t heir
experiences w ith i magined s ituations o f o thers o r o neself
Being m indful:
o Be a ware o f o ur o wn e motions t hat a rise a s a r eaction t o
patients e motions o r a s w e e mpathize w ith p atients
o Be a ware o f t he d istinction b etween o ur o wn e motions a nd t he
emotions o f o thers
o Remain c alm d uring a n e motional c risis o f p atients o r f amily
members
62

SECTION 3:

END-OF-LIFE CARE AND

ETHICS

63
CHAPTER 12: PROGNOSTICATION

INTRODUCTION
Prognostication refers to the skill of predicting survival or outcome of a
situation. Clinicians may or may not be aware of it but prognostication is an
essential tool which we use every single day when making clinical decision. It is
the b asis b y w hich w e d ecide o n t he n ature a nd a ggressiveness o f o ur t reatment
and interventions. It is also the basis by which we will communicate issues of
risks of mortality and morbidity and weigh the ethical balance of performing an
intervention.
Without bearing in mind the overall prognosis of a patient, it is impossible to
make clear ethical decisions and communicate meaningful information to the
family o f a p atient f acing s erious illness.
ASSESSING P ROGNOSIS
In m anaging p atients a pproaching t he e nd-of-life, t he c linician s hould f irst a sk
several q uestions r egarding p rognosis:
1.
2.
3.
4.
5.
Does t his p atient h ave a n incurable c ondition? If s o, w hat is t he

evidence f or s aying t his?
At t his s tage o f t he illness, a re t here a nymore o ptions o f d isease
modifying t herapies a vailable t o t his p atient?
If t his p atient u ndergoes d isease-modifying t herapies, w hat is t he
probability o f a p ositive o utcome a nd w hat a re t he r isks o f a
negative o utcome?
If t here is h igh p robability o f p ositive o utcome b ut r isk o f n egative
effects a s w ell, is t he p atient w illing t o t ake t he r isks?
Finally, if o ptions h ave b een e xplored a nd t here is n o o ther
interventions t o b e c onsidered, w here d oes t his p atient s tand in
his/her d isease t rajectory.
64
DISEASE T RAJECTORIES
Overall t here a re 3 m ain t rajectories o f p atients w ith c honic incurable illness
(Murray e t a l 2 005)
INCURABLE C ANCER
C HRONIC O RGAN F AILURE
S TROKE, D EMENTIA,FRAILTY

65
O nce the patients disease trajectory is well understood, the clinician will then
have a better feel on how to estimate a patients overall prognosis. The overall
prognosis m ust a lso t ake into a ccount t he individual p atients c haracteristics.
There are many prognostication prediction tools and scoring systems that help
to guide clinicians to understand better where a patient stands in their disease
trajectory a nd t hese c an b e f ound in t he a ppendices a t t he e nd o f t his b ook.
HOW IS THIS USEFUL IN CLINICAL PRACTICE?

By u nderstanding a p atients o verall p rognosis, t his w ill h elp c linicians:
Determine what kind of interventions are appropriate to suggest in a

particular p atients c ondition. ( ie. a ggressive c hemotherapy is a ppropriate in
a fit young patient with breast cancer but is less appropriate in a frail
patient w ith liver c ancer a nd m ultiple c o-morbidities)

Navigate discussions with patients and family members in order to help
them be clearer on the problems being faced and to express their choices
and w ishes f or t he f uture.

Determine the overall goals of care. Prognosis is all about the direction in
which patients are headed hence without knowledge of this, it is difficult to
decide o n w here a p atient w ould like t o b e ( ie. g oals o f c are)

Communicate the severity of illness to family members and to justify
witholding o r w ithdrawing f utile interventions if a ppropriate.
66
CHAPTER 13: END-OF-LIFE CARE

DR. SIOW YEN CHING, MBBS(IMU), MRCP(UK)

INTRODUCTION

The terminal phase is defined as the period when day to day deterioration of
strength, appetite and awareness are occurring in a patient with an incurable
and p rogressive illness. P riorities o f c are in t his p hase include:

Recognising the likelihood that death will occur soon and
communicating t his s ensitively t o f amily a nd s ignificant o thers.
Involving the dying person and family in decisions about treatment and
preferences f or c are.
Explore needs of the dying person and family and attempt to meet
these a s f ar a s p ossible.
Individualise plan of care which includes food and drink, symptom
control and psychological, social and spiritual support, is agreed, co-
ordinated a nd d elivered w ith c ompassion.

ASSESSMENT - D IAGNOSING D YING

Stages
Characteristics/ S igns

Bed b ound
Early
Loss o f interest a nd/or a bility t o d rink/eat
Cognitive c hanges: increasing t ime s pend s leeping a nd/or
delirium

Further d ecline in m ental s tatus t o o btundation ( slow t o
Middle
arouse w ith s timulation; o nly b rief p eriods o f
wakefulness)
Death r attle p ooled o ral s ections t hat a re n ot c leared
due t o loss o f s wallowing r eflex

Coma
Late
Altered r espiratory p attern G asping, p eriods o f a pnoea,
hyperpnoea, o r i rregular b reathing
Mottled e xtremities, c old e xtremities ( signs o f
hypoperfusion)

67

Recognition of patients who are actively dying is key for clinicians to
provide the most appropriate interventions for both the patient and
family.
The time to traverse the various stages can be less than 24 hours or as
long a s 1 4 d ays.
Exclude reversible causes of deterioration such as infection, electrolytes
imbalances or medications side effects if the deterioration occurs
unexpectedly and the investigations involved are aligned with patients
wish.

ASSESSMENT P ATIENTS N EEDS

Examination is k ept a t t he m inimum t o a void u nnecessary d istress:
o Observe f or a ny n on v erbal indication o f d iscomfort.
o Be m indful o f p ainful a reas.
Minimise investigations / b lood t aking
o Only investigations t hat a re a bsolutely n ecessary a nd m ay
impact o n t he c omfort a nd g oals o f t he p atient.
o Choose least invasive a nd t roublesome investigations.
Physical n eeds
o bowel a nd b ladder c are
o oral c are- k eeping t he m outh m oist
o skin c are a nd p revention o f p ressure s ores
o specific s ymptoms s uch a s p ain, n ausea, v omiting a nd
breathlessness.
Psychological a nd s piritual n eeds
o Anxiety a nd f ear
o Respecting p atients s piritual a nd r eligious n eeds. A llowing
specific r eligious p ractices w here p ossible.
Review m edications
o Medications w ith n o b enefit a t t his p hase ( eg. a ntihpt,
antiplatelets, s tatins, v itamins) s hould b e s topped a nd r easons
of s topping e xplained t o f amily / carers.
o Essential m edications s uch a s a nalgesia a nd a nxiolytics m ay b e
changed f rom o ral t o s ubcutaneous r oute i s a bility t o s wallow is
diminished.

68
MANAGEMENT

Continuation o f s ymptom r elief
o All medications for pain, dyspnoea and nausea should continue
even w hen i n t erminal p hase a nd l ess r esponsive.
o If u nable t o s wallow, c hange t o S C r oute in e quivalent d ose.

Artificial n utrition a nd h ydration.
o There is a consistent lack of benefit of artificial nutrition (NG
tube, TPN) and hydration (IV/SC drip) in prolonging life
expectancy a nd i mproving q uality o f l ife a t t he t erminal p hase.
o Family members often view nutritional and hydration as a
source of care and support. Thus, the discussion about the role
of artificial nutrition or hydration needs to be done sensitively
to f ind a b alance b etween e vidence a nd e motions.

Oral C are
o Oral care is very important at the terminal phase, this is
because poor oral hygiene and dry mouth can lead much
discomfort.
o Dry mouth is due to decrease oral intake, stomatitis, oral
breathing a nd s ide e ffects o f o pioids.
o Family should be encouraged to clean patients mouth with
cotton or orange stick wrapped with gauze dipped in sodium
bicarbonate s olution.
o Keep mouth moist with small amount of fluids through a spray
bottle, s yringes o r c otton s ticks.

Noisy b reathing/ D eath r attle
o This is due to secretions collecting in airways which are no
longer b eing c oughed o r c leared a s n ormal.
o Family should know that the secretions are not causing
suffocation, c hoking o r d istress.
o Elevating patients head by 30 degrees or laterally may allow
the d rainage o f s ecretion.
o Anti-cholinergic a gents t o d ry s ecretions:
SC H yoscine b utylbromide ( buscopan) 6 0-240mg/24 h ours a s
continuous C I infusion ( CSCI) a nd 2 0mg p rn
SC G lycopyrrolate 6 00-1200mcg/24 h ours(CSCI) o r 2 00-
400mcg T DS

69
Suctioning is often not recommended in death rattle as deep

suctioning will not improve secretions and may cause further
distress to the patient. It is only useful for pooled secretions in
the o ral c avity. F amily s hould b e informed a bout t his.

Terminal A gitation / R estlessness
o Where possible, rule out reversible causes of delirium and
restlessness.
o In the dying phase if no reversible factors noted, terminal
agitation is a s ymptom o f t he d ying p hase.
o Explain t o f amily t he c ause is d ue t o t he b ody shutting d own.
o Sedation is appropriate and ethical when the patient is clearly
distressed.
Confused a nd d elirious, c onsider a n a ntipsychotic:
SC h aloperidol 0 .5-5mg O N o r a s C SCI/24 h ours
Merely a gitated u se b enzodiazepine:
SC m idazolam 2 .5mg s tat a nd e very 3 0 m ins p rn
If p ersistent c onsider C SCI m idazolam 1 0-60mg/24 h ours
Delirious a nd a gitated:
Combine a ntipsychotic w ith b enzodiazepine
Refractory s evere a gitation:
may r equire u se o f d rugs s uch a s p henobarbitol, p ropofol o r
levomepromazine ( requires s pecialist c onsultation)

Anticipatory M edications
o Always h ave P RN d oses o f m orphine, m idazolam a nd b uscopan
prescribed in a nticipation o f w orsening o f s ymptoms a t a ny t ime:
th
Pain / d yspnoea
SC m orphine ( 1/6 o f 2 4hour d ose) P RN
Nausea / v omiting
SC h aloperidol 0 .5-1mg P RN
Agitation / d elirium SC m idazolam 2 .5-5mg P RN
SC h aloperidol 0 .5-1mg P RN
Secretions
SC h yoscine b utylbromide 2 0mg P RN
SC g lycopyrrolate 2 00mcg P RN

70
CHAPTER 14: END-OF-LIFE CARE IN ICU

DR. TAI LI LING, MD(UKM), MMED(ANAES), EDIC(BEL);
DR. LOUISA CHAN, MBBS(SYD), FJFICM(AUS);
DR NOOR AIRINI IBRAHIM, MBBS(UM), MMED(ANAES), EDIC(UK);
DR. AHMAD SHALTUT OTHMAN ,MBBS, MMED(ANAES)

INTRODUCTION

The primary goal of intensive care is to treat acute reversible life-threatening
conditions so that patients survive with acceptable functional status and quality
of life. While providing therapeutic interventions, clinicians should also attend
to patients discomfort and control any distressing symptoms. However, when
death appears inevitable or the possibility of restoring meaningful life becomes
remote, t he p atient s hould b e a ccorded a d ignified d eath.
WHO WILL NOT BENEFIT FROM INTENSIVE CARE?
The clinician is obligated to provide the best possible service within the
confines of limited resources. Following this, the priority of admission
into the intensive care unit shall be for the critically ill patients who are
most likely t o s urvive a nd r esume a f unctional life.

Patients w ho a re h ighly u nlikely t o b enefit f rom life-support t herapy
include:
o Severe, irreversible brain condition impairing cognition and
consciousness
o End stage cardiac, respiratory or liver disease with no options
of t ransplant
o Metastatic c ancer u nresponsive t o t reatment
o Advanced age with poor functional status due to multiple
chronic o rgan d ysfunctions
o Severe d isability w ith p oor q uality o f life
o Advanced d isease o f p rogressive life-limiting c ondition
o Those who have explicitly stated their wish not to receive life-
support t herapy
o The goals of care for such patients should have ideally been
discussed earlier with them or their families before they
become c ritically ill.
71
PROGNOSTICATION OF INTENSIVE CARE OUTCOME
Prognostication of critically ill patients being treated in the intensive

care unit is never easy or precise. Severity scoring systems are of
limited v alue in p redicting o utcome in individual p atients.

The clinician needs to draw from his own expertise and experience in
identifying patients who are unlikely to benefit from further aggressive
life-support therapy. Besides reviewing the patients course of disease,
the clinician must weigh the benefits against the burden of continuing
life s upport t herapy.

End-of-life discussion with the family (or patient, whenever possible)
should be initiated early, sometimes even upon admission and not
necessarily wait untill the burden of treatment outweighs the benefit.
The patient can continue to receive life-support therapy following
initiation o f e nd-of-life d iscussion u ntil a f inal d ecision is m ade.

End-of-life decision should be integrated with the patients or familys
values and hence strict evidence-based decision cannot be applied.
These d ecisions n eed t o b e individualised.

The determinants of poor intensive care outcome are multifactorial.
They are not to be considered in isolation, but in the context of the
entire history and clinical status of the patient. Some of the
determinants listed below can help the clinician recognise when to
initiate d iscussion o n e nd-of-life d ecisions
o Severity o f illness
o Multi-organ f ailure
o No p eriod o f c linical improvement d espite o ptimal t herapy
o Pre-existing advanced chronic condition e.g. congestive cardiac
failure, c hronic lung d isease, c hronic liver d isease

72
History o f c ardiac a rrest

Recurrent ICU a dmission d uring s ingle h ospital a dmission
Recurrent unplanned hospital admission within the last 6
months
o Poor and deteriorating performance status prior to admission
e.g. NYHA Class 3 or 4, limited self-care, > 50% of the day spent
in b ed.
o Underlying diagnosis remains unknown despite extensive
investigations

When faced with prognostic uncertainty, treatment should be
continued to allow a clearer assessment to be made with additional
time a nd c onsultation w ith o ther c linicians.
o
o
o
WITHDRAWAL OR WITHHOLDING OF LIFE-SUPPORT THERAPY
As the patients critical illness progresses and when the burden of

treatment options outweighs its benefit, the clinician should initiate
discussion on withdrawal or withholding of life-support therapy. Allow
the patient a natural and dignified death by not prolonging the dying
process.

There is no single way to withdraw or withhold life-support therapy in

the critically ill. The actual practice needs to be individualised to
address physical, psychological, social and spiritual needs of the patient
and f amily.

When the direction of care has changed from curative intent to

comfort, the principles of palliative care should be enforced, including
maintaining comfort and dignity, controlling symptoms, attending to
psychological a nd s piritual n eeds, a nd s upporting t he f amily.

The steps in decision-making to withdraw or withhold life-support

therapy a re o utlined b elow.
o Obtain medical consensus among the teams managing the
patient.

73
o
o
Communicate the decision to the family (or patient, whenever

possible) and guide them to concur with the medical decision.
This shared decision-making should be done by a senior
clinician w ho h as b uilt a r apport w ith t he f amily.
Allow the family time to come to terms with the impending loss
of t heir loved o nes.
In the event of disagreement between the clinician and the
family, a time-limited trial of therapy with clear goals of
treatment is a n a pproach f requently u sed in c onflict r esolution.
All decisions regarding the withdrawal or withholding of
therapy should be documented in the patients case notes. It
should include the basis for the decision, with whom the
decision was made, and specific treatments to be withheld or
withdrawn.
WITHDRAWAL O F M ECHANICAL V ENTILATION
The ethical principles of withdrawal or withholding mechanical

ventilation a re s imilar t o o ther m edically inappropriate t herapies.

Despite no ethical difference between withdrawal or withholding of

mechanical ventilation, the former usually generates more concern
because the possible short interval from withdrawal to death may be
mistaken for terminating the patients life. In actual fact, the intention
in withdrawing mechanical ventilation, a treatment no longer of any
benefit, is t o s top p ostponing d eath.

The practical aspects of withdrawal from mechanical ventilation are

outlined b elow:
o Prepare and educate the family on what to expect to help
reduce f ear a nd e ncourage involvement.
o De-medicalise the process by minimising monitoring,
deactivating alarms and discontinuing laboratory or radiological
tests.
o Discontinue a ny m edication o r t herapy t hat d oes n ot c ontribute
to p atient c omfort e g. v asoactive a gents, a ntibiotics, d ialysis.

74
o
o
o
Initiate analgesia with continuous intravenous opioids if the

patient is not already on. Consider a loading dose and titrate to
effect. Intravenous benzodiazepine may be added to treat
anxiety. The principle of double effect of opioids is ethically
acceptable. The beneficial effect of relieving of pain and
symptoms is intended and outweighs the side-effects of
depressing v entilation a nd p erhaps, h astening d eath.
Perform suction of endotracheal tube, gastric tube and
oro/nasopharynx t ube.
Position the patient slightly lateral with head minimally
elevated.
Administer atropine or glycopyrolate if there is excessive
respiratory s ecretions.

There are basically 2 methods of withdrawal of mechanical ventilation.
The p rimary o bjective in e ither c ase is t he p atients c omfort.

o Terminal weaning (i.e. gradually reducing the set ventilator
parameters w hile leaving t he e ndotracheal t ube in p lace)

This method allows for better titration of sedatives and may be

less traumatic to families, though it may prolong the dying
process. It may be the preferred option in patients who have
excessive r espiratory s ecretions.

Terminal extubation ( i.e. r emoval o f t he e ndotracheal t ube a nd
the p atient s pontaneously b reathes r oom a ir)

Terminal extubation removes the discomfort from the

endotracheal tube and restores the natural end-of-life
process. However, the family may interpret the ensuing noisy
breathing or agonal breaths as discomfort. This method may
also b e m isinterpreted a s a bandonment o f c are.

Reassess f requently t o e nsure p atient c omfort a nd b e a ttentive t o t he n eeds
of t he f amily.
75
CHAPTER 15:ETHICS IN PALLIATIVE CARE

DR. LAM CHEE LOONG, BMEDSCI, BMBS , MRCP(UK)
INTRODUCTION
Clinical ethics in practice concerns decision making and the reflections, process
and reasoning in attempting to reach the right moral choices. Decisions
regarding health care delivery are not always clear cut and the right choices for
one may not always be what is right for others. While no model of ethics is
totally c omprehensive a nd a ll e ncompassing, t he B iomedical M odel is o ften u sed
for its accessibility and applicability in practice. It does not give answers, rather
provides a f ramework t o h elp w eigh u p d ecisions.
BIOMEDICAL MODEL OF ETHICS
4 p rinciples:
o Autonomy - the right of an individual to govern themselves and
make d ecisions c oncerning t heir c are
o Beneficence - actions should seek to do good and bring benefit to
patients
o Non-maleficence - n o h arm s hould b e d one
o Justice - b eing f air, t o t he p atient, o thers, a nd s ociety

The principles themselves may sometimes be in conflict but they should all
be c onsidered in a ttempting t o r each a d ecision c oncerning m edical c are.
Alongside t hese p rinciples, s everal o ther f actors w arrant c onsideration
o Respect f or t he s anctity o f life
o A d octors d uty t o a lleviate s uffering
o Goals of care (Curative vs life prolonging/controlling vs
comfort/palliation)
o U tility - d oing t he m ost g ood f or t he m ost p eople
o Proportionality - every treatment has benefits and harms/burdens.
Actions t aken s hould p roduce m ore g ood t han h arm

76
CHAPTER 15: ETHICS IN PALLIATIVE CARE

An e xample o f a n e thical d ilemma:
A 92 year old lady lives in a nursing home and has advanced dementia. She is
admitted for a third time in the last 6 months with pneumonia. She has no
mental capacity to make decisions herself. Functionally, she is bedbound and
conscious but unable to converse normally. She requires assistance with all
aspects of daily care - feeding, toileting, dressing, bathing. There is also a grade
III p ressure s ore. H er f amily r equest t hat a ll b e d one t o s ave h er life.

Issues t o p onder:

Autonomy
o Does s he t ruly lack c apacity f or d ecision m aking?
o Did s he e xpress w hat s he w ould w ant p rior t o t his?
o Is h er f amilys r equest b ased o n h er v alues o r t heir o wn?
o Is k eeping h er a live w hat s he m ay h ave w ished f or?
Beneficence
o Antibiotics may help the infection and improve survival but
further a spiration is likely. Is t reatment t ruly b eneficial?
o Will nasogastric feeding help? As this does not entirely prevent
aspiration w ill it g ive a t rue b enefit?
Non-maleficence
o Overall prognosis from advanced dementia with aspiration is
poor hence does prolonging her life do more harm in terms of
quality o f life a nd p rolonging s uffering?
o Is t reatment b urdensome - c annulation, b lood t ests?
o Will ventilation cause more harm in terms of discomfort and
loss o f d ignity?
Justice
o is c ontinuing t reatment f air t o t he p atient?
o Is s topping t reatment a n infringement o n h er r ight t o life?
o Are the costs of the treatment and nursing home fair to the
patient a nd h er f amily?
o Would utilizing resources be appropriate in this circumstance
when t hey m ay b e s pent in o ther a reas?

What a re t he g oals o f c are? It m ay b e e asier t o f ollow t he f amily w ishes, b ut is it
the r ight c hoice f or t he p atient t o w hom o ur d uty lies?

77
Ethical decision making requires weighing up all pros and cons given as
much information a nd u nderstanding o ne c an g ather o f a c ase.
If in d oubt, d iscuss t he c ase w ith o thers f or m ore c larity.
Our a ttitudes a nd o wn v alued judgments s hould n ot influence t he d ecision.
CARDIOPULMONARY RESUSCITATION

Cardiopulmonary Resuscitation (CPR) is a potentially life saving intervention

but a complex issue as conflicts may arise between the expectations of the
patient, f amily, a nd d octors a s t o its r isks a nd b enefits.
Decisions regarding CPR only determine whether CPR will be performed or
not in t he e vent o f a c ardiac a rrest
It refers to the practice of performing CPR ALONE, and does not influence
the p receding a nd s ubsequent c are
DNAR (Do not attempt resuscitation) decisions DO NOT mean basic or
medical care are stopped - fluids, antibiotics, feeding and other care
measures or interventions may still be appropriate after a DNAR decision
has b een m ade
DNAR decisions may not foresee all circumstances - a r eversible, u nforeseen
event may require intervention (eg choking on a foreign body or an acute
haemorrhage)
DNAR decisions are case-by-case decisions not blanket policies for patients
with p articular u nderlying d iagnoses
Many deaths are foreseeable and it is good medical practice to make
resuscitation decisions actively to prevent what may be inappropriate or
unnecessary t reatment

In attempting to make a DNAR decision, the following factors should be
borne in m ind
o Effective a nd c lear c ommunication is p aramount
o There is n o s pecific r equirement t o r aise r esuscitation d ecisions if a
cardiac a rrest/deterioration i s n ot a nticipated u nless r equested b y
the p atient

78
o
o
o
o

If a cardiac arrest occurs unexpectedly, a default presumption for
CPR is reasonable and treatment should administered with the goal
of r eversing t he e vent
Is C PR likely t o b e a f easible/appropriate t reatment o ption?
In some circumstances, CPR is very unlikely to succeed, particularly
in actively dying patients. There is no absolute obligation to provide
it if the medical team feel it is not a valid treatment option and
attention should be focussed on communicating the situation and
prognosis, plans to proactively manage comfort and preparing the
patient a nd f amily f or a n imminent d eath u nambiguously
If C PR m ay b e a f easible/appropriate t reatment o ption in a m entally
competent p atient, t he i ssue s hould b e d iscussed c learly, a ccurately
and honestly with the patient if they wish to participate in the
discussion (or chosen representative with the patients consent)
and a d ecision a greed.
If CPR may be feasible/appropriate in someone lacking mental
capacity, t he f ollowing s hould b e a scertained
Presence of an Advance Directive/Living Will/Advance
Decision t o R efuse T reatment
Proxy decision maker from an Advance Care Plan to assist
the d ecision m aking
What the patients views and wishes would have been had
they h ad m ental c apacity t o g uide a b est interest d ecision
The patient and family may seek a second opinion if they are not
satisfied w ith t he p rimary t eam d ecision
Decisions should be communicated to the rest of the team and
reviewed if c ircumstances c hange
Patients have rights to treatments but at the same time, there is no

absolute professional obligation that a doctor must conform to a patients
wishes a nd a ccede t o d emands.
In any decision/action, the patient is always the priority and the doctor
must a ct f or t he g ood o f t he p atient.

79
EUTHANASIA AND ASSISTED DYING

Euthanasia is illegal in Malaysia. It remains a challenging, and often poorly
understood topic as definitions vary. Actions may often be misinterpreted
and m isunderstood a s t he p ractice o f e uthanasia.

By itself, the term euthanasia, derived from Greek, refers to (a) good (eu-)
death (thanatos).In clinical practice however, the practice of euthanasia
refers to deliberate actions that intentionally hasten the death of a patient,
at the patients request, in order to relieve intractable suffering and
distress.

Some K EY a spects o f e uthanasia a re:
o INTENTION/GOAL is to cause the death of a patient successful
outcome is f or immediate d eath t o o ccur
o It must ALWAYS be voluntary the patient must competently
request for it. If the patient is unconscious or does not request for
it, t he a ction is m urder.
o It must always be ACTIVE t he doctor must deliberately perform an
action that is expected to cause death. (Passive euthanasia is
therefore a misnomer and withholding life sustaining treatment is
not e uthanasia.)
o It intends t o r elieve s uffering b y K ILLING t he p erson.

Assisted Dying, also known as Physician Assisted Suicide (PAS) or Physician
Assisted Dying, is also illegal in Malaysia. In this situation, the physician
provides the means for a patient to end their life however the action of
taking the life is conducted by the patient. Eg. providing lethal dose of
medications t o c ommit s uicide.

In Malaysia as euthanasia is illegal, any act of euthanasia can be charged
under t he p enal c ode a s m urder o r c ulpable h omicide.

80
WITHDRAWAL AND WITHHOLDING TREATMENT

In some circumstances, the withdrawal and withholding of life sustaining
treatments is s ometimes justifiably p racticed in m edicine, p articularly w here:

A p atient d eclines intervention, o r r equests a n intervention b e s topped.
- In accordance with the practice of autonomy (unless the patient
lacks m ental c apacity).
Treatment is d isproportionate ( burdens o utweigh b enefits)
- The role of a doctor is not to distress patients further with
treatments t hat h ave n o/limited b enefits.
Medical f utility
- Where a treatment is very unlikely to work, either from a very
low likelihood of success, to an inability to restore a
quality/function o f life a cceptable t o a p atient.

Cessation or withholding of treatment on these grounds is different from
euthanasia i n t hat:

INTENTION/GOAL is to respect autonomy, or stop a treatment that is very
unlikely to work to achieve a goal, or to relieve a patient from a distressing
treatment administered by a physician with little benefit. The GOAL is NOT
TO H ASTEN D EATH
The b est interest is t o r espect a utonomy o r r elieve s uffering f rom a m edical
action that health care providers are delivering that is not achieving the
desired o utcome. D EATH is N OT t he b est interest
It stops suffering through the REMOVAL/WITHHOLDING of a medical
intervention a nd n ot k illing

The patient MAY die as a result of the withdrawal/withholding of treatment but
if death does not follow, no further action to hasten it should take place. Death
is a possible consequence, but not the goal of withdrawal and withholding. The
action taken and intention of the action is not to bring about death. Death is
actually caused by an underlying, irreversible medical condition, or a condition
that a p atient v olitionally r efuses t reatment a dministered f or t heir o wn r easons.

81

The role of medicine is not to subject competent people to treatments they
refuse, neither is it to continue burdensome and futile treatments that may be
painful a nd d istressing, a nd a ctually c ause s uffering.

People have a right to live, and they also have a right to allow natural
progression of disease to occur especially when medicine no longer works, or
they n o longer w ish t o r eceive it.

If trials of treatment are instituted, the option of stopping them, even life
sustaining treatments, should be open, particularly if the goals of medicine are
not b eing a chieved a nd m ore h arm is b eing d one.

Decisions o n w ithdrawing a nd w ithholding life s ustaining t herapy s hould n ot
be m otivated b y a d esire t o b ring a bout d eath

Withdrawal a nd w ithholding o f t reatment if p racticed a ppropriately,
is N OT E UTHANSIA

ADVANCE CARE PLANNING (ACP)

Is a v oluntary p rocess involving p atient

May take place with or without the family present although decisions and
discussions should be shared to increase awareness and facilitate the
patients w ishes
Made b y p atients w ho h ave d ecision m aking c apacity
Is not a one-off encounter where decisions are made and fixed as views
may c hange o ver t ime a nd a s s ituations e volve.
Care p lans s hould b e r eviewed r egularly t o e nsure c onsistency a nd v alidity
The details, depth and extent of ACP discussions is patient
determined/driven b ut m ay r equire s ome g uidance
The d ecisions s hould b e f ree f rom c oercion

82

The A CP p rocess m akes e nquiries t o u nderstand f actors s uch a s:
o Patient values, thoughts and attitudes towards life, healthcare
preferences a nd t he v iews o f t he f uture
o Goals, wishes in life, what is important, and what makes life
worthwhile
o Ideas, c oncerns, a nd e xpectations o f c urrent h ealth
o Preferences of care - place of care, place of death, how, where
and w ho t o s pend last d ays w ith
o Treatment preferences and dislikes, worries, difficulties,
unacceptable s ituations
o Generally, anything the patient would like or feel open to
discuss r egarding f uture c are
Following discussions, a clearer picture and understanding should be
gained r egarding a p ersons:
o Preferred p lans f or c are a nd w hat is important t o t hem
o Wishes a bout c are ( treatments c annot b e d emanded b ut w ishes
guide w hat is p referred/acceptable)
o Advance Medical Directives (usually refusals for specific
treatments in c lear c ircumstances)
o Preferred p eople t o a ct a s p roxy d ecision m akers

Refusals o f t reatment/Advance M edical D irectives/Living W ills

For a r efusal o f a life s ustaining m edical t reatment t o b e v alid

o It must be clear that the patient is refusing it even though
death m ay b e a c onsequence
o It h as t o b e s pecific t o t he s ituation
o Must be made when mentally competent and without undue
influence
They should generally be respected if made by a competent patient unless
there a re g rounds t hat indicate t hey m ay b e invalid.

Plans, w ishes, s tatements, d irectives a nd g uidance f rom a n A CP o nly b ecome
active w hen m ental c apacity is lost a nd t hey h elp g uide d ecision m aking.
At its c ore, A CP is a bout o pen a nd g ood c ommunication.
83
Generally, A CP is a pplicable t o e veryone a nd a t a ny t ime. In t erms o f d irect

and immediate r elevance, it w ould b e s uited t o p atients w ith a limited
prognosis s uch a s:
o Advanced c hronic illness - c hronic h eart f ailure, c hronic
respiratory d isease, c hronic k idney d isease, n eurodegenerative
disorders ( dementia, m otor n eurone d isease), e tc.
o Incurable c ancer
o Acute illnesses n ot r esponding t o t reatments
When t o s tart A CP d iscussion?

o Ask t he s urprise q uestion, Would y ou b e s urprised if t his
patient d ied in t he n ext 1 2 m onths? If a nswer is n o, it m ay b e
appropriateto s tart A CP if a p atient w ishes.
o Repeated a dmissions o f increasing f requency m ay a lso indicate
a d eclining c ondition.
ACP a ims t o a llow p atients t o g uide a nd a ttempt t o t ake c ontrol o f t heir

healthcare d ecisions in t he e vent t hat t hey a re u nable t o m ake d ecisions
themselves in o rder t hat t heir p references a nd w ishes m ay b e r espected.
Family m embers m ay n ot a lways k now w hat a p atient w ishes u nless t his h ad
been d iscussed b efore a nd it m ay h elp r educe f amily s tress in d ecision
making.

Ideally, A CP s hould b e d ocumented a nd s hared w ith k ey c are p roviders.

In M alaysia a dvanced m edical d irectives a re n ot legally b inding h owever t he
good c ommunication, r espect f or a utonomy, p atient c entred c are a nd s hared
decision m aking a re a ll a spects o f g ood c onduct a nd p ractice in d elivering h igh
quality c are.

84
MENTAL CAPACITY

Mental capacity indicates an ability to make ones own decisions regarding

issues.
Mental capacity may fluctuate over time and repeated efforts should be
made to restore and reassess the integrity of the patients capacity at a
different t ime.
Presumption o f c apacity:
o all adults may make decisions on their behalf unless it can be
proven o therwise
o the onus of proof of mental incapacity rests with the person
challenging i t
Mental capacity may vary depending on the complexity of the decision at
hand - a lack of capacity for a particular decision does not indicate
incapacity f or a nother t ype o f d ecision.
A p oor d ecision t hat h ealthcare s taff d o n ot a gree w ith d oes n ot n ecessarily
indicate a lack o f m ental c apacity.

Test o f c apacity

Is there is a concern that there is an impairment or disturbance in the
function o f t he m ind o r b rain?
o If the answer is NO, then the patient is presumed to have mental
capacity
o If Y ES, p roceed t o c heck:

1. Can t he p erson t ake in a nd u nderstand t he information r elevant t o
the d ecision?
2. Can t he p erson r etain t he information long e nough t o m ake t he
decision?
3. Can t he p erson w eigh u p t he information a nd r each a d ecision?
4. Can t he d ecision b e c ommunicated?

All p ractical e fforts s hould b e t aken t o p rove m ental c apacity is intact
e g: p rovide i nterpreter, u se w riting, g estures a nd p sychiatric a ssessment.

85
Failure of any of the four steps indicates a person lacks capacity for the
specific d ecision a t h and.
Efforts should be made to improve their mental capacity if reversible causes
are interfering ( eg t reating d elirium o r a ddressing d epression)
A b est interest d ecision m ay n eed t o b e m ade in t he interim.

Best interests

Best interest decisions should encompass thoughts, both advantages and
disadvantages o n t he f ollowing d imensions:
o Medical c onsequences - o utcome, b urdens a nd b enefits
o Welfare consequences - impact on how (better or worse) the
person lives t heir life
o Social c onsequences - e ffects o n r elations, r elationships a nd s ociety
o Emotional consequences - how the patient may feel about the
decision
o Ethical consequences - specific ethical considerations in reaching a
decision

Advanced Care Plans if available may help guide a best interest decision in
informing o n v alues a nd b eliefs.
R elatives and others familiar with the patient may be consulted to provide
views o n p atients v alues a nd b eliefs.

86
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of t he E uropean A ssociation f or P alliative C are. J C lin O ncol 2 3(25):6240-6248. D OI:
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.
88
APPENDIX 1:MODIFIED CHARLSON CO-MORBIDITY INDEX FOR ESRF
Comorbidity
Coronary a rtery d isease
Congestive c ardiac f ailure
Peripheral V ascular D isease
Cerebrovascular D isease
Dementia
COPD
Diabetes w ithout e nd-organ
damage
Connective T issue D isease
Peptic U lcer D isease
Mild L iver D isease
1 p oint f or e ach c ondition
Every d ecade a bove 4 0
1 p oint e ach d ecade ( 65 y rs =

3 p oints)
Hemiplegia
Mild t o s evere r enal d amage
(including b eing o n d ialysis)
Diabetes w ith e nd-organ d amage
Cancer ( including leukemia a nd
lymphoma)
2 p oints f or e ach c ondition
Moderate t o s evere liver d isease
3 p oints
Metastatic s olid t umour

AIDS
6 p oints f or e ach c ondition
Modified
CCI S core
Totals
Annual
Mortality
rate
Points
Low S core Moderate

( 3 o r less)
(4-5)
0.03
0.13
89
High
(6-7)
0.27
Very H igh
(8 o r m ore)
0.49
APPENDIX 2 : BODE INDEX FOR COPD

Variable
FEV1 ( % p redicted)

Distance w alked in 6 m ins ( metres)
0
>65
>350
Points
1
2
50-64
36-49
250-
349
2
MMRC d yspnoea s cale

0-1

Body-Mass Index
>21
<21

Correlation o f B ODE s core w ith m ortality
BODE s core
1-year
2-year
mortality
mortality
0-2
2%
6%
3-4
2%
8%
5-6
2%
14%
7-10
5%
31%

90
3
<35
150-
249
3
<149
52-month
mortality
19%
32%
40%
80%
APPENDIX 3: PALLIATIVE PROGNOSTIC SCORE FOR CANCER

Prognostic F actor
Dyspnoea
Absent
Present
Anorexia
Absent
Present
Karnofsky P erformance S tatus
>50
30-40
10-20
Clinicap p rediction o f s urvival
>12 w eeks
11-12 w eeks
9-10 w eeks
7-8 w eeks
5-6 w eeks
3-4 w eeks
1-2 w eeks
Total W BC c ount ( cell/mm3)
Normal: 4 ,800-8,500
High: 8 ,501-11,000
Very H igh: > 11,000
Lymphocyte p ercentage
Normal: 2 0.0%-40.0%
Low: 1 2.0% - 19.9%
Very low: 0 %-11.9%
Score
Partial S core

0
1

0
1.5

0
0
2.5

0
2.0
2.5
2.5
4.5
6.0
8.5

0
0.5
1.5

0
1.0
2.5
30 d ay s urvival
probability
0-5.5
>70%
5.6-11.0
30-70%
11.1-17.5
<30%
91
APPENDIX 4 : LIST OF ABBREVIATIONS

ACP
Advanced C are P lan
Aq
Aqueous
BD
Latin: b is in d ie ( Bidaily)
COX-2 -
Cyclooxygenase-2
COPD -
Chronic O bstructive P ulmonary D isease
CPR
Cardiopulmonary R esuscitation
CSCI
Continuous S ubcutaneous Infusion
CT
Computed T omography
CVS
Cardiovascular
DVT
Deep V enous T hrombosis
DNAR -
Do N ot A ttempt R esuscitation
Eg
Latin: E xempli g ratia ( for e xample)
Etc
Latin: e t c etera ( and o ther t hings)
GI
Gastrointestinal
IV
Intravenous
ICU
Intensive C are U nit
NSAIDs -
Non-Steroidal A nti-Inflammatory D rugs
NG
Naso-Gastric
NYHA -
New Y ork H eart A ssociation
OD
Latin: o mne in d ie ( Once d aily)
ON
Latin: o mne n octe ( Every n ight)
PRN
Latin: p ro r e n ata ( as n eeded)
92
LIST OF ABBREVIATIONS

SC
Subcutaneous
SSRI
Selective S erotonin R euptake Inhibitor
SVCO
Superior V ena C ava O bstruction
Sy
Syrup
Tablet
TD
Transdermal
TDS
Latin: t er d ie ( three t imes a d ay)
TPN
Total P arenteral N utrition
QID
Latin: q uarter in d ie ( four t imes a d ay)
93
APPENDIX 5 : LIST OF PALLIATIVE CARE SERVICES & HOSPICES

PALLIATIVE C ARE S ERVICES
HOSPITAL
TEL
WEBSITE
Institut Kanser Negara*
03-88925555
http://www.moh.gov.my
Hospital Selayang, Selangor*
03-61203233
http://www.hselayang.moh.gov.my
Pusat Perubatan Universiti Malaya,

Kuala Lumpur *
Pusat Perubatan Universiti
Kebangsaan Malaysia, Kuala Lumpur *
Clinical Trial Centre, Universiti
Teknologi MARA, Sg Buloh*
Hospital Tuanku Jaafar, Negeri
Sembilan
Hospital Melaka, Melaka
Hospital Raja Permaisuri Bainun,
Perak
Hospital Bukit Mertajam, Kedah
Hospital Sultanah Bahiyah, Kedah
Hospital Pulau Pinang, Pulau Pinang
Hospital Tengku Ampuan Afzan,
Pahang
Hospital Sultanah Nur Zahirah,
Terengganu
Hospital Raja Perempuan Zainab II,
Kelantan
Hospital Queen Elizabeth, Sabah
Hospital Duchess of Kent, Sabah
Hospital Tawau, Sabah
Hospital Umum Sarawak, Sarawak
03-79494422
http://www.ummc.edu.my
03-91455555
http://www.ppukm.ukm.my
03-61265000
http://www.medicine.uitm.edu.my
06-7623333
http://www.htjs.moh.gov.my
06-2707653
05-5222245
http://www.hmelaka.moh.gov.my
http://www.hipoh.moh.gov.my
04-5383333
04-7303333
04-2293333
09-5133333
http://www.hospbm.moh.gov.my
http://www.hsbas.moh.gov.my
http://www.hpp.moh.gov.my
http://www.htaa.moh.gov.my
09-6233333
http://www.hsnzkt.moh.gov.my
09-7485533
http://www.hrpz2.moh.gov.my
088-206258
089-212111
089-773533
082-208069
http://www.qeh.moh.gov.my
http://www.hdok.moh.gov.my
http://www.htwu.moh.gov.my
http://www.hus.moh.gov.my
*Centres w ith S pecialist P alliative C are s ervice

94
LIST OF PALLIATIVE CARES SERVICES AND HOSPICES

PALLIATIVE C ARE S OCIETIES/HOSPICES
SOCIETY
TEL
WEBSITE/E-mail
Malaysian Hospice Council
03- 33242125
Hospis Malaysia
03-91333936
Hospice Klang (Covering

Klang area)
03-33242125
http://www.hospiceklang.org
hpsklang@gmail.com
Kasih Hospice Care Society

(Covering North KL up to Sg
Buloh/Rawang area)
03-79607424
http://www.kasihfoundation.org
admin@kasihfoundation.org
Assunta Palliative Care

Centre (Covering South KL
Kajang/Bangi area)
Pertubuhan Hospice Negeri
Sembilan
Hospice Malacca
Palliative Care Association
of Johor, JB
03-79543389
Aspacc.assuntahospital@gmail.com
06-7621216
012-6235115
07-2229188 /
07-2228858
http://pertubuhanhospicenegerisembilan.com
hospicens2012@yahoo.com
drrajagopal@hotmail.com
http://www.pcajb.com
nancyyee.pcajb@gmail.com
Persatuan Hospice Ark, JB
07-5560878
Hospice_ark@hotmail.com
Persatuan Hospis Pahang

Persatuan Hospis
Terengganu
Persatuan Hospis Kedah
018-5994614
09-8593333
hospispahang@gmail.com
Drnona31765@gmail.com
04-7713487
Persatuan Hospis Negeri

Kelantan
NCSM Penang
09-7452000
http://hospiskedah.blogspot.com
sriwahyu2006@yahoo.com.my
drimisairi@yahoo.com
Penang Hospice Society
04-2284140
Pure Lotus Hospice of

Compassion, Penang
Perak Palliative Care
Society (PPCS)
Taiping Palliative Society
04-2295481
04-2284140
05-5464732
05-8072457
http://www.malaysianhospicecouncil.blogspot.com
malaysianhospicecouncil@gmail.com
http://www.hospismalaysia.org
info@hospismalaysia.org
http://www.ncsmpenang.org
ncsmpg@gmail.com
http://www.penanghospice.org.my
penanghospicesociety@gmail.com
lyanshih@gmail.com
http://www.ppcs.org.my
admin@ppcs.org.my
veraliew@hotmail.com
95
LIST OF PALLIATIVE CARES SERVICES AND HOSPICES

PALLIATIVE C ARE S OCIETIES/HOSPICES
SOCIETY
TEL
WEBSITE/E-mail
Kuching Hospice Cancer
Care
Sarawak Hospice Society
082-337689
cancercare@gmail.com
082-276575
Home Care Hospice

Programme, Kota Kinabalu,
Sabah
Palliative Care Association
of Kota Kinabalu, Sabah
Persatuan Hospis Tawau
The Hospice Association of
Sabah, Sandakan
Persatuan Hospice St
Francis Xavier, Keningau,
Sabah
088-222315
http://www.sarawakhospicesociety.org
tangtiengswee@gmail.com
http://www.sabah.org.my/scss/cancer
sabahcancersociety@yahoo.com
088-231505
http://www.sabah.org.my/pcakks
pcakk@yahoo.com
hospistwu@gmail.com
http://www.hospicedk.com
hospicesandakan@yahoo.com.my
Lucyliew41@gmail.com
089-711515
089-632219
087-339114
96
97

Handbook of Palliative Medicine in Malaysia

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4

Message f rom t he P resident o f C ollege o f P hysicians,

Message f rom t he N ational A dvisor f or P alliative M edicine,

Palliative C are: D efinition a nd C oncept

Section 1 : M anagement o f P hysical S ymptoms

Chapter 1 : C ancer P ain

Chapter 2 : R espiratory S ymptoms

Chapter 3 : G astrointestinal S ymptoms

Chapter 4 : N eurological S ymptoms

Chapter 5 : O ral C are

Chapter 6 : S kin C are

Section 2 : P sychosocial C are, S piritual C are a nd C ommunications

Chapter 8 : S piritual C are

Chapter 9 : R eligious D iversity

Chapter 1 0: C ommunication S kills

Chapter 1 1: H andling E motions

Section 3 : E nd-of-Life C are a nd E thics

Chapter 1 3: E nd-of-Life C are

Chapter 1 4: E nd-of-Life C are in ICU

Chapter 1 5: E thics in P alliative C are

Appendix 1 : M odified C harlson C o-Morbidity Index f or E SRF

Appendix 2 : B ode Index f or C OPD

Appendix 3 : P alliative P rognostic S core f or C ancer

Appendix 4 : L ist o f A bbreviations

Appendix 5 : L ist o f P alliative C are S ervices & H ospices in M alaysia

MESSAGE FROM PRESIDENT OF

active management that is appropriate to relieve symptoms and provide

MESSAGE FROM NATIONAL ADVISOR

PALLIATIVE CARE: DEFINITION AND

WHAT IS PALLIATIVE CARE?

provides r elief f rom p ain a nd o ther d istressing s ymptoms;

PALLIATIVE CARE: DEFINITION AND CONCEPT

IS PALLIATIVE CARE ACTIVE MEDICINE?

IS PALLIATIVE CARE ALL ABOUT DEATH AND DYING?

PALLIATIVE CARE: DEFINITION AND CONCEPT

WHEN AND WHERE DO PATIENTS NEED PALLIATIVE CARE?

Integrated Model of Palliative Care

Disease-modifying therapy (curative,

CHAPTER 1: CANCER PAIN

Somatic pain due to direct tissue damage by cancer in bone, muscle or

CHAPTER 1: CANCER PAIN

P P lace / S ite o f p ain ( Where is t he p ain?)

CHAPTER 1: CANCER PAIN

Use the WHO analgesic ladder by selecting analgesia according to pain

CHAPTER 1: CANCER PAIN

CHAPTER 1: CANCER PAIN

Managing s ide e ffects o f m orphine a nd o ther o pioids

CHAPTER 1: CANCER PAIN

CHAPTER 2: RESPIRATORY SYMPTOMS

Lung c ancer o r lung

Cardiac f ailure / P ulmonary

CHAPTER 2: RESPIRATORY SYMPTOMS

Symptomatic management of breathlessness if unable to reverse

CHAPTER 2: RESPIRATORY SYMPTOMS

Managing m alignant p leural e ffusions

CHAPTER 2: RESPIRATORY SYMPTOMS

Similar t o b reathlessness, r eversible c auses s hould b e t reated.

Via vagus nerve - gastric distension, gastritis, GERD, hepatic tumors,

CHAPTER 2: RESPIRATORY SYMPTOMS

NAUSEA & VOMITING

Vomiting i n r elation t o o ral i ntake is t his m echanical?

CHAPTER 3: G.I. SYMPTOMS

Correct a ny r eversible c auses

Consider a s 3 line w hen m etoclopramide a nd