Five Common Palliative Care Emergencies
The type and likelihood of a palliative care emergency depends on the nature of the individual’s condition, symptoms and state of health. Based on feedback from home-based palliative care providers, the CHCA has identified 5 common palliative care emergencies: dyspnea, hypercalcemia, hemorrhage, seizures, and finally spinal cord compression and superior vena cava obstruction. All home-based palliative care providers should be able to identify the signs and symptoms of these common emergencies. Remember the 5Bs: breathing, bleeding, balance, brain, and blockage.
1. Breathing (Dyspnea)
- Breathing difficulties and shortness of breath can be caused by a variety of issues, including pulmonary and cardiovascular problems, anemia, pain and psychological distress.
- Dyspnea is common among patients receiving palliative care and it is a leading cause of trips to the emergency department.
Symptoms of dyspnea can include accessory muscle use (increased work of breathing), tachycardia (elevated heart rate), tachypnea (increased respirations), pallor or cyanosis (colour change) and stridor.
2. Bleeding (Hemorrhage)
- Bleeding from the respiratory or gastrointestinal tract may occur directly from a tumour, blood vessels or as a result of the underlying medical condition (blood and platelet disorders).
- Losing small amounts of blood is not an emergency, but may be a warning for more extensive bleeding in the future.
- A catastrophic hemorrhage is a life-threatening emergency, and can be very distressing for patients, family members, caregivers and health care providers. Patients who have a massive hemorrhage can quickly deteriorate.
Signs of a massive hemorrhage can include: haemoptysis (coughing up blood); haematemesis (vomiting blood); melena (dark, tarry bowel movements caused by bleeding in the stomach or upper gastrointestinal system); bloody bowel movements or bleeding from the rectum; hematuria (blood in the urine) or bleeding from ulcers, tumours or wounds on the skin.
3. Balance (Hypercalcemia)
- Hypercalcemia is a high level of calcium in the blood, which can be caused by calcium leaching from the bones.
- This complication is common in patients with advanced cancers and can lead to kidney and heart problems, bone pain, forgetfulness, lethargy, as well as nausea and vomiting.
Signs and symptoms of hypercalcemia vary and can be caused by other cancer-related problems or treatment. Use this mnemonic device to remember the symptoms: “hypercalcemia can cause stones, bones, abdominal moans, and psychiatric groans”2
4. Brain (Seizures)
- Seizures may occur in patients with brain tumours (primary or metastases), stroke, organ failure, neurological/neurodegenerative diseases, and drug/medication withdrawal can experience seizures.
- Patients with known seizure disorders are at risk when unable to take oral medications to control their seizures.
Signs of a seizure can be difficult to detect and may be simple or complex. Seizures characterized by generalized, full body (tonic–clonic) shaking are easily recognizable. More subtle seizures can be quite difficult to identify and can include may include twitching or stiffness in the body, rolling of the eyes or staring at a fixed point or inability to move.
5. Blockages (Spinal Cord Compression and Superior Vena Cava Obstruction)
- Seizures may occur in patients with brain tumours (primary or metastases), stroke, organ failure, neurological/neurodegenerative diseases, and drug/medication withdrawal can experience seizures.
- Patients with known seizure disorders are at risk when unable to take oral medications to control their seizures.
Spinal cord compression
- Often experienced by patients with tumours of the vertebrae, which cause the spinal cord to be pinched or squeezed.
- It is not uncommon to confuse the symptoms of spinal cord compression with other causes.
- A patient’s leg weakness may be attributed to a decline in health or deconditioning; urinary and bowel symptoms might be attributed to medication.
- Without treatment, spinal cord compression can cause loss of sensation, paralysis, or incontinence.
Symptoms include pain, numbness, or trouble with coordination.
Superior vena cava obstruction
- A condition where blood returning to the heart from the upper body is blocked.
- Usually the result of a tumour within the mediastinum, a tumour in the vessel wall or a clot in the vessel (thrombosis).
- Obstruction of blood flow results in severe upper body congestion
Symptoms include headache, a feeling of pressure in the head and face, swelling of the eyes, face, neck, arms and hands, changes in vision and distention of the neck.