Administering esomeprazole subcutaneously via a syringe driver in the palliative demographic: A case series.

WHAT IS KNOWN AND OBJECTIVE: Proton pump inhibitors are potent suppressors of gastric acid secretion, and are commonly prescribed in palliative medicine. Despite multiple relevant indications in patients at the end-of-life, their use is often precluded as oral and intravenous administration is frequently inappropriate or not possible. Limited anecdotal evidence suggests proton pump inhibitors may be administered subcutaneously. Our objective was to investigate the tolerability and effectiveness of the administration of esomeprazole as a continuous subcutaneous infusion over 24 h via a syringe driver. METHODS: Case series (n = 7) design assessing sequential patients admitted to a specialist inpatient centre for palliative care, who required parenteral proton pump inhibitor therapy. RESULTS AND DISCUSSION: Four patients reported complete resolution of dyspeptic and reflux symptoms post commencement of esomeprazole. Two patients developed upper gastrointestinal bleeding, which via observation of vomitus and stools, resolved with the initiation of esomeprazole. A single patient, deemed high risk of gastrointestinal bleeding, was commenced on esomeprazole and no bleeding events occurred. WHAT IS NEW AND CONCLUSION: Esomeprazole when administered via a syringe driver over 24 h appears well tolerated and effective for the symptomatic management of dyspepsia and treatment of gastrointestinal bleeding. Overall, this series adds to the limited evidence base for using subcutaneous proton pump inhibitors in the palliative demographic.

Glycopyrrolate and the Management of "Death Rattle" in Patients with Myasthenia Gravis.

Death rattle commonly occurs at the end of life and is typically managed with anticholinergic agents. Myasthenia gravis is an autoimmune disorder characterized by fatigability of skeletal muscle, resulting from autoimmune destruction of acetylcholine receptors at the motor endplate. The condition is treated with acetylcholinesterase inhibitors, which potentiate the action of acetylcholine. Agents that antagonize acetylcholine activity (e.g., anticholinergic agents, such as glycopyrrolate) can, therefore, exacerbate myasthenia gravis. We discuss the case of a patient dying with myasthenia gravis that developed problematic "death rattle," and the successful use of glycopyrrolate in treating this symptom.

Subcutaneous Olanzapine at the End of Life in a Patient with Schizophrenia and Dysphagia.

Currently, there is a paucity of evidence to guide the management of antipsychotic therapy at the end of life for patients with schizophrenia. A 51-year-old female with a diagnosis of palliative squamous cell carcinoma of the tonsils was admitted to her local hospice for end-of-life care. She had a history of treatment-resistant schizophrenia, which was ordinarily managed with oral clozapine and aripiprazole. Owing to a deteriorating swallow and the inappropriateness of other enteral administration routes for this patient however, it became necessary to consider alternative means by which to give essential antipsychotic medicine. A subcutaneous infusion of olanzapine was chosen as the most viable solution. During the course of the admission, her schizophrenia began to relapse with the onset of positive psychotic symptoms (paranoia and hallucinations). This was posited as likely due to interruption of her regular oral antipsychotic medication combined with insufficient olanzapine dosing. The olanzapine dose was thus subsequently titrated over the course of a week with close monitoring, and her psychotic symptoms abated. Owing to a protracted dying phase, the patient remained on subcutaneous olanzapine for a total of 56 days, which allowed for accurate assessment of her psychiatric symptoms and evaluation of therapeutic response. The findings of this case report suggest that subcutaneous olanzapine may be an appropriate alternative for patients who are unable to take their complex oral antipsychotic regimens through enteral routes at the end of life.

Administering Neostigmine as a Subcutaneous Infusion: A Case Report of a Patient Dying With Myasthenia Gravis.

BACKGROUND: Abrupt withdrawal of pharmacological therapies for myasthenia gravis can exacerbate muscle weakness and even trigger myasthenic crisis. Such medications should ideally be continued, but how this can be achieved in patients approaching the end of life, particularly when enteral administration is compromised, has not been defined. CASE HISTORY: An 83-year-old man with a history of generalized myasthenia gravis and palliative metastatic anal adenocarcinoma was admitted to his local hospital with general decline, where he was considered by more than one physician to be actively dying from his cancer. In the days preceding admission, the patient had not taken his medications consistently, including the acetylcholinesterase inhibitor, pyridostigmine, for the management of his myasthenia gravis. CASE MANAGEMENT AND OUTCOME: Reintroduction of the patient's usual myasthenia therapy improved his clinical condition to the point where he was no longer thought to be dying. When enteral administration of pyridostigmine was no longer possible, the patient was successfully converted to neostigmine, which was administered as a continuous subcutaneous infusion. CONCLUSION: Undertreated myasthenia gravis can lead to a rapid deterioration in a patient's clinical condition, and such patients may be mistakenly diagnosed as dying. Undertreated myasthenia gravis should therefore be considered as a potentially reversible cause of acute deterioration, especially in patients with complex comorbidities. The use of neostigmine as a continuous subcutaneous infusion may have a role in the management of such patients, particularly when enteral administration of acetylcholinesterase inhibitors is no longer possible.

A qualitative study of nursing staff experiences of delirium in the hospice setting.

BACKGROUND:: Delirium is a common condition occurring in 13-42% of people admitted to palliative care units and up to 88% of these patients are at the end of their lives. It is frequently unrecognised and distressing to all those affected-patients, families and health professionals. In addition, there is considerable uncertainty surrounding its trajectory and optimal management, both of which can be inconsistent. AIMS:: This study aims to explore the experience of nursing staff who are caring for patients with delirium in the hospice environment and understand any potential barriers to its management. METHODS:: Semistructured interviews using emotional touchpoints were conducted with 12 nurses and six healthcare assistants in three hospices in North East England. Data was analysed using interpretative phenomenological analysis. FINDINGS:: The results highlighted gaps in knowledge and understanding in the management of delirium. The results demonstrated delirium had significant emotional effects, which were associated with uncertainty in managing the condition and the impact of this uncertainty on the relationship between staff and patients. CONCLUSION:: This study highlights the emotional impact of caring for patients with delirium. Future work is needed to address the areas of uncertainty identified and ascertain how to best support nursing staff in these challenges.

Screening for delirium in specialist palliative care inpatient units: perceptions and outcomes.

OBJECTIVES: The UK National Institute for Health and Care Excellence (NICE) indicate that palliative care patients are at high risk of delirium and should be screened for it using the short confusion assessment method (short CAM). This study aimed to assess the perceptions of the short CAM for delirium screening amongst health-care workers in specialist palliative care inpatient units (SPCUs) and to investigate its use as a screening instrument. METHODS: Patients in 5 SPCUs in the North East of England were screened for delirium using the short CAM and a staff survey assessed the acceptability of the short-CAM in this setting. RESULTS: Of the 63 staff surveyed, 79.4% felt screening for delirium was important and 59.3% found the short CAM 'not at all' burdensome to complete. However, only 40.7% felt that the short-CAM often accurately reflected patients' conditions and none felt it always accurately reflected patients' condition. Of 298 patients screened, 20% screened positive on the short CAM. Malignant and intra-cerebral diseases were significant independent predictors of a positive screen. Hospice length of stay and in-hospice mortality were higher in those with a positive result (66.7%) than in those without (38.2%). CONCLUSIONS: Health professionals deem delirium screening to be important in SPCUs, but may not support routine use of the short CAM. This could reflect a limited perceived impact on care and lack of confidence in this tool to reflect a complex patient group.