Palliative Care in the Bush
You are a GP in a remote town 400 km from the nearest palliative care specialist. A 72-year-old woman with metastatic breast cancer is at home, cared for by her elderly husband. She has severe bone pain, nausea, and is bedbound. Current medications: oral morphine 10 mg every 4 hours as needed (she is taking about 6 doses/day), metoclopramide 10 mg TDS, and paracetamol 1 g QID. She is now unable to swallow tablets due to nausea. Her husband is her sole carer and is exhausted. The community nurse visits twice weekly. There is no hospice bed available. You have access to a small hospital with 2 beds, but it is 50 km away. What is your approach to managing her symptoms and supporting her husband?
1. How would you manage her pain and nausea given she cannot swallow? Discuss medication options and routes.
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Pain management:
- Convert to subcutaneous or intravenous morphine: Since she cannot swallow, use subcutaneous (SC) morphine. Calculate total daily dose: she takes about 6 x 10 mg = 60 mg/day oral morphine. Convert to SC: oral to SC ratio is approximately 2:1 or 3:1. So SC dose would be 20-30 mg/day. Use a syringe driver for continuous SC infusion if available, or intermittent SC injections every 4 hours. If syringe driver not available, consider SC boluses.
- Alternative: If SC route not feasible, consider rectal morphine (if suppositories available) or transdermal fentanyl (but not ideal for unstable pain).
- Adjuvant analgesics: For bone pain, consider adding NSAID (if renal function okay) or bisphosphonate, but she cannot swallow. SC ketorolac? Not recommended long-term. Consider SC clodronate? Not available. Palliative radiotherapy would be ideal but requires travel; discuss with specialist via telehealth.
- Breakthrough pain: SC morphine 5-10 mg as needed.
Nausea management:
- Antiemetic: Metoclopramide oral not possible. Use SC metoclopramide 10 mg TDS, or SC haloperidol 0.5-1 mg BD, or SC ondansetron 4-8 mg TDS. Choose based on cause (e.g., metoclopramide for gastric stasis, haloperidol for chemical causes).
- Consider other causes: Constipation (common with morphine) – use SC or rectal laxatives. Hypercalcaemia – check calcium; treat with SC fluids and bisphosphonates if available.
Other symptoms:
- Constipation prophylaxis: SC or rectal laxatives.
- Anxiety/dyspnoea: Consider SC midazolam if needed.
Route: SC is preferred. Ensure husband and nurse are trained to give SC injections. If not, hospital admission may be needed.
Justification: Converting to SC route ensures symptom control when oral route unavailable. Syringe driver provides continuous comfort. Addressing nausea and constipation improves quality of life.
2. How would you support her husband and plan for her end-of-life care in this remote setting? Discuss the role of the community nurse, respite, and advance care planning.
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Supporting husband:
- Assess carer burden: He is exhausted. Acknowledge his efforts and provide emotional support.
- Respite: Arrange for additional community nurse visits or a volunteer carer. Consider admission to the small hospital for respite or symptom control to give him a break. If hospital bed available, use it.
- Education: Teach him how to administer SC medications, recognise signs of deterioration, and when to call for help. Provide written instructions and emergency contact numbers.
- Telehealth support: Arrange telehealth sessions with palliative care specialist for advice and support for both patient and husband.
- Financial and practical support: Link with social worker for financial assistance, home help, and equipment (e.g., hospital bed, commode).
End-of-life planning:
- Advance care directive: Discuss goals of care, preferred place of death, and resuscitation wishes. Document in patient's record. Involve husband in discussions.
- Community nurse role: Increase visits to daily if possible. Nurse can administer SC medications, monitor symptoms, and support husband. Coordinate with GP.
- Hospital admission: If symptoms uncontrolled or husband unable to cope, admit to small hospital for palliative care. Ensure staff trained in palliative care.
- Bereavement support: Plan for support for husband after death.
Justification: Supporting the carer is essential to enable home death if desired. A coordinated approach with community nurse and telehealth specialist ensures quality care. Advance care planning respects patient autonomy and prepares for deterioration.