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Palliative Care Prioritisation during the COVID-19 crisis

Underlying principles

  1. Oncology patient care must continue to prioritise the relief of severe distress and the management of severe acute complications of cancer
  2. Many symptom control issues can be managed by telephone consultations
  3. Whenever possible, home care services should be arranged for patients with anticipated high palliative care needs

Prioritising

Oncology services should continue to provide urgent evaluation and management of severe complications of cancer such as:

  1. Spinal cord compression
  2. Impending fractures and pathological fractures
  3. GI obstructions: upper, lower, biliary
  4. Nausea
  5. Emesis
  6. Acute obstructive renal failure
  7. Severe dyspnoea
  8. Thrombosis and pulmonary emboli
  9. Severe anaemia
  10. Severe thrombocytopaenia
  11. Effusions: symptomatic pleural effusion, pericardial tamponade, tense ascites
  12. Superior vena cava obstruction
  13. Brain metastases; especially if complicated by seizures, focal neurological deficits, cognitive impairment
  14. Delirium
  15. Pain and other severe symptoms not adequately controlled by optimal home management
  16. Severe refractory symptoms at the end of life not adequately controlled by optimal home management

 

Practical suggestions for treatments

  1. Ensure that patients have adequate supply if analgesics or other medication are needed for their symptom control
  2. Proactively monitor patients with anticipated high care needs by telemedicine (this can be delegated to the nursing team)
  3. When palliative RT is needed for bone metastases or cord compression, single-fraction therapy should be used (if deemed clinically reasonable)
  4. Patients with far advanced disease should be managed at home as much as possible
  5. Permanent indwelling catheter drainage systems (such as PleurX) should be used for patients needing frequent drainage of pleural effusion or ascites

High Priority

  • Symptoms suggestive of spinal cord compression: strong increasing back or neck pain, radicular pains. Patient requires urgent radiological evaluation and possibly RT or surgery.  When possible, consider single-fraction RT
  • Symptoms suggestive of impending fracture: severe hip or leg pain standing or walking. If surgical stabilisation is not available, at least offer single-fraction RT
  • Severe pain of any cause (7-10/10), uncontrolled by optimal home management
  • Severe increasing dyspnoea (7-10/10) except with known extensive lung metastases: may have pleural effusion or pulmonary embolus needing urgent treatment. Patients with recurrent effusions: consider PleurX drain systems for home care
  • Symptoms of upper GI obstruction: abdominal distension with vomiting
  • Symptoms of lower GI obstruction: abdominal distension with pain and absolute constipation
  • Severe nausea and vomiting due to other causes
  • Symptoms suggestive of superior vena cava compression: face or arm swelling
  • Symptoms suggestive of brain metastases: seizures, headache with confusion or focal neurological defects
  • Major bleeding: haematemesis, haemoptysis, rectal bleeding
  • Anaemia Hb <7 g/dL (not terminally ill), Hb 7-8 g/dL symptomatic
  • Symptoms of biliary obstruction: new onset jaundice, dark urine, fever
  • Symptoms of deep venous thrombosis: leg or arm swelling and pain
  • New onset-agitated delirium
  • Severe emotional distress with active suicidal ideation
  • Symptomatic cerebral metastases in patients with otherwise good PS. RT (try to minimise need for steroids)

Medium Priority

  • Moderate back pain (ESAS 4-6)
  • Back pain with inadequate control and frequent use of rescue doses
  • Severe increasing dyspnoea with known extensive lung metastases: provide telephone guidance. Consider admission if home care services are inadequate
  • Postprandial vomiting: try to arrange for GI evaluation and imaging. May need stent or NGT
  • Hb 7-8 g/dL not symptomatic
  • Increasing anxiety and/or depression
  • Asymptomatic cerebral metastases. Monitoring. Treatment can be delayed

 Low Priority

  • Mild back pain
  • Mild moderate focal skeletal pain
  • Mild stable dyspnoea
  • Occasional vomiting
  • Constipation
  • Minor blood in sputum, blood on toilet paper
  • Hb <7 g/dL terminally ill, Hb >8 g/dL
  • Jaundice in patient with known extensive liver metastases
  • Mild arm or bilateral leg swelling
  • Progressive confusion in patient with known extensive brain metastases, liver metastases or advanced renal failure
  • Mild/moderate anxiety and/or depression
  • Symptomatic cerebral metastases in patient with poor PS or close to end of life. Trial of treatment with dexamethasone 16 mg/day

 

List of abbreviations: COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; ESAS, Edmonton Symptom Assessment Scale; Hb, haemoglobin; GI, gastrointestinal; NGT, nasogastric tube; PS, performance status; RT, radiotherapy.

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