Surgical palliation

Incurable end-stage head and neck cancer leads to distressing symptoms. Patients may remain active and self-caring while trying to cope with problems of pain, swallowing, breathing and bleeding. Palliative surgery may be indicated in such cases. Little high-level evidence is available to confirm the surgical benefit; however, descriptive studies support its use in selected cases. Surgery can reduce primary tumour bulk, reduce pain and bleeding, improve swallowing, nutrition and improve and airway (see below). Debulking surgery for advanced neck disease can achieve symptom control, but major resections only rarely offer levels of benefit, which justify the extent of surgical morbidity.

Newer endovascular techniques, including embolisation and vessel stenting, may offer symptom control for bleeding related to major vascular erosion, and these interventions can be considered in patients at high risk of erosion of major vessels.

Acute haemorrhage from carotid ‘blow-out’ (erosion of the carotid vessels) is a distressing end of life event. Whilst occasional success can be achieved with swift surgical intervention, many patients succumb rapidly. In these cases, attempts to reduce the flow of blood with direct pressure while administering appropriate rapid acting sedatives (e.g. benzodiazepines) should be made. Constant verbal support to the patient is a key to help handle anxiety. Do not leave the patient's side.

If surgical intervention is considered inappropriate careful discussion and measured information giving to the patient (if they wish to participate) or family members and carers is essential. This should include the anticipated clinical scenario and an acceptable plan of care should be devised to manage these circumstances. This may include the use of dark towels, anticipatory prescribing, and may influence preferred place of care.

Non-surgical palliation

Palliation of dysphagia

Forty per cent of patients with head and neck cancer suffer from dysphagia. This is due to:

• • mechanical obstruction

• • functional obstruction

• • drug induced side effects

• • fistula

• • pain.

Assessment of the swallow is essential in palliative head and neck patients. It is important to establish whether oral intake is possible and whether it is safe. Aspiration is not uncommon and may be silent in up to 40  per cent of patients, thus the bedside assessment is of limited value. Functional endoscopic evaluation of swallowing (FEES) is straightforward, easily repeatable, portable and can give good information on the aetiology of aspiration as well as feedback to the patient on trials of preventative manoeuvres. It can also be useful in the assessment of ability to deal with different textures and complements information obtained from videofluoroscopy.

Aspiration does not inevitably mean no oral intake. A degree of aspiration may be well tolerated and methods taught to clear the airway after swallowing can be implemented. Similarly certain textures may be better tolerated and the use of thickened fluids can help maintain oral intake. It is important to take into account the patient's wishes and the patient may make an informed choice to continue to swallow despite the potential and real risk of aspiration pneumonia. Quality of life is absolute.

In patients who are unable to swallow, the use of an enteral route via nasogastric tube (NGT) or gastrostomy allows for hydration, nutrition and medication. The type of tube used depends largely on ability to pass an NGT or fashion a gastrostomy, perceived duration of use and patient choice. If enteral nutrition via NGT is likely to extend beyond two to three weeks then gastrostomy should be considered and discussed with the patient.

There exists no clear guidance on when or if it is acceptable to withdraw nutritional support. Patient and family wishes are crucial in this decision process and full consultation is imperative.

Conventional treatments can be helpful in the palliation of swallowing. Surgical debulking either with or without the laser or debrider and RT may help reduce bulk in a hypopharyngeal tumour, dilatation can help in stricture formation and this can be surgical or radiologically guided. Stenting may play a role but often head and neck tumours are too high to accommodate a stent comfortably and without impacting on other functions.

Palliation of the airway

Where there is airway compromise it is common practice to consider a tracheostomy. However, it may be possible to avoid tracheostomy in some cases if the consideration is given to surgical debulking techniques. This is dependent on local expertise and equipment.Reference Wee and Hillier ⁵

Sometimes avoiding surgical intervention is the most appropriate course of action, for example, a patient with a tracheal tumour that has been repeatedly debulked, and has received palliative RT, is not a candidate for stenting. There will come a time when the airway compromise will be life threatening. A tracheostomy may not be an option in this instance. In such instances opioids for dyspnoea in addition to palliative sedation and reduction of secretions can support a patient in a terminal event.

These situations are difficult and information should be imparted to the patient sensitively. In the situation where the patient wants to fully discuss the anticipated scenario a sense of control can be restored to them by discussing what interventions can be undertaken pharmacologically to avoid any distress. If the patient does not want to participate in the discussion this should be documented and discussed with family and/or carers. This situation may influence the preferred place of care. To have the patient and the family prepared for the event is paramount. They must know what will be in place to prevent the dyspnoea and anxiety associated with such a situation and the patient must be comfortable to the end.

If a tracheostomy is indicated local protocols should exist or be developed to help the patient, the family and community staff manage tracheostomy wound care along with maintenance of a clean secure tube. Heat moisture exchange and voicing attachments may be used to aid patient communication.

Pain

Pain is very common, affecting most patients at any stage. It may be disease or treatment related, either acute and/or immediate or persistent and/or lifelong. Pain occurring after a long, pain free interval is likely to be recurrent disease. Assessment must take account of the presence of ‘total pain’ i.e. physical, spiritual, psychological and social elements. The three major pain types are all encountered – somatic, visceral and, particularly difficult, neuropathic.

Analgesic use is best based on the World Health Organization (WHO) ‘pain ladder’ (Box II) with three steps of increasing potency, and used depending on pain severity and response. The severity of the pain dictates the strength of the analgesic and the pathophysiology dictates the adjuvant used.

The choice of formulation depends on whether the patient can swallow, is vomiting, or has a nasogastric (NG) or gastrostomy tube in situ.

Nausea and vomiting

The approach must take an account of the large number of patients who are enterally fed. Even with this there is often a need for injectable anti-emetics – subcutaneous (SC) boluses or continuous infusions, at least until initial control is established.

Enteral feeding poses its own challenge, and prokinetic drugs such as metoclopramide (tablet, oral solution or injection) or domperidone (tablet, suspension or suppository) may be needed to ensure best function.

Otherwise the approach is similar to that in general use. Remember the practical issue of providing a large bowl, tissues and water for the patient and be prepared to rehydrate using IV or SC fluids if appropriate.

Constipation

Constipation develops in half of patients who are terminally ill with cancer admitted to a hospice. In addition, it is common during treatment in many patients. This is due to dehydration, reduced physical activity and the use of constipating drugs, particularly opioids and anticholinergic medication. Laxatives should be initiated once opioid medication is prescribed. Hypercalcaemia and hypothyroidism are other causes, which may be overlooked.

The principle of treatment is avoidance and early recognition. Enquiry should be made on patient contact. Laxative agents include stimulants such as bisacodyl and senna and softeners such as lactulose, magnesium hydroxide and docusate. Polyethylene glycol preparations including movicol and laxido are commonly used. These should be used prophylactically. If constipation develops it can lead to nausea and vomiting and in the severe situation pseudobstruction. If rectal examination reveals hard stool then the use of suppositories and enemas can be helpful. Ultimately, a manual evacuation may be necessary.

Confusion and agitation

It is important to distinguish anxiety (unsettled, frightened, panic) from confusion, particularly delirium. Confusion is common, affecting up to 75 per cent of cancer patients at some stage. Many head and neck patients have a history of heavy alcohol (and tobacco) consumption, predisposing them to the effects of withdrawal, and given that cancer is more commonly seen in old age; then cognitive impairment is not uncommon.

Benzodiazepines are the mainstay of pharmacological treatment of anxiety. Diazepam can be given orally, via a tube in liquid form, or by injection intravenously. Lorazepam can be swallowed or a tablet dissolved sublingually. If injections and/or infusions are needed, midazolam is preferred, as it can be given subcutaneously (most common route) or intravenously when almost immediate effect is needed. The key limiting factor, however, is rapidly developing tolerance; benzodiazepines are useful for short-term management of episodes of anxiety, but are limited where anxiety is pre-existing and established.

Delirium as a cause of confusion can be related to a number of organic causes – infection, dehydration, metabolic disturbance, respiratory failure, urinary retention, constipation, brain metastases, etc. Administered drugs are common causes, particularly opioids and drug withdrawal (see above). While treatment has to be aimed at the cause, symptom management is required in the short term. While benzodiazepines have a role, indeed a specific indication in drug withdrawal, most often delirium is better managed using haloperidol (as tablet, liquid or injection, including SC) or levomepromazine (as tablet or injection) where sedation is needed in managing paranoia etc.

In some cases, particularly for irreversible agitation or delirium in a dying patient, benzodiazepines and antipsychotics need to be combined and are often administered using a syringe driver.

Secretions

Although xerostomia is common in these patients, excess secretions and/or the inability to swallow or otherwise clear secretions is often troublesome. Physically the use of suction either by carer or the patient is often helpful.

There are three widely used antimuscarinic drugs.

• • Hyoscine hydrobomide (scopolamine) is available as a transdermal patch, oral or sublingual tablet and is commonly used; however, it has central as well as peripheral actions and (unpredictable) sedation and/or confusion can result.

• • Hyoscine butylbromide, which is not central nervous system active, but equally effective peripherally, and is arguably the drug of choice. It is available as a tablet, though often ineffective by that route; hence SC use may be preferred.

• • Glycopyrronium, which is similarly peripherally active, and is most often given subcutaneously. A liquid form can be prepared but efficacy is unpredictable.

• • Excess secretions at the end of life are treated similarly, but the evidence in a Cochrane review suggests they are of very limited benefit. Established practice accepts SC preparations of anticholinergic medication are available for use to support this end of life phase. Timely management is a key here; if secretions develop, then regular or continuous antisecretory drugs should be started as soon as practical, rather than relying on PRN drugs.

Steroids

As with other cancers, corticosteroids are widely used. Dexamethasone (Table I) is the most used, because of its potency, relative lack of mineralocorticoid properties, and wide range of formulations (water soluble tablets, solution, and injection, SC or intravenous).Reference Hardy, Rees, Ling, Burman, Feuer and Broadley ⁶

$$\hbox{Dexamethasone}\; 1\,\hbox{mg} = \hbox{Prednisolone}\; 7.5\,\hbox{mg}$$

Table I

Indications and dosage for steroid (dexamethasone) use

Long-term use also requires that attention be paid to bone mineral density, and bisphosphonates, and calcium and/or vitamin D supplements are indicated.

If used for any length of time patients must carry a ‘steroid card’, keep it up to date, and be aware of the advice on it, i.e. to increase the dose when there is intercurrent illness or other stressor; and the need to reduce very gradually if used for more than three to four weeks – including at the end of life. Some advise that steroids given for poor appetite or fatigue can be discontinued then. This puts the patient at risk of steroid insufficiency, an unnecessary symptom burden even at that stage, and dexamethasone can be given in small volumes subcutaneously once daily, as part of end of life care if appropriate.

Spinal metastases

The incidence of spinal metastases in head and neck squamous cell carcinoma is reported to be less than 2 per cent; however, it is more common in thyroid cancer (2–13  per cent). The most important factor in determining outcome is neurological status prior to treatment. Due to the devastating neurological sequelae of spinal cord or cauda equina compression early recognition (Box III) and action is essential and consideration that symptoms may be suggestive of spinal metastatic disease is the first step. ⁷

Neurological symptoms and signs should be assessed and a magnetic resonance imaging of the whole spine obtained. This is an oncological emergency and steroids should be commenced while investigations or admission are arranged. Treatment depends on findings and includes steroids, surgical stabilisation and RT. Clear guidelines on diagnosis and management have been published by National Institute for Health and Care Excellence (NICE) and the readers should familiarise themselves with these. ⁷

Decisions around CPR

Where a cardiac arrest is a significant possibility, where CPR has a reasonable chance of success, and where no advance decisions have been made with respect to resuscitation, then CPR should be attempted. Examples of such cases include acute reversible illnesses or treatable arrhythmias. Similarly, if a cardiac arrest is unlikely, then CPR should be attempted if it occurs. Examples here include the otherwise healthy person admitted with a relatively minor illness or an out-of-hospital arrest in public. A presumption of patient consent exists here, and it is not relevant to discuss in advance unless requested (and in such a case, patient wish should be respected). Whilst this is applicable to many hospital patients, it is less relevant to palliative care patients, in whom life-threatening events are more likely, and CPR is less likely to succeed.

At the other extreme, where a patient is dying and no reversible causes for their condition exist, then CPR is inappropriate. In this context, cardiac arrest may be viewed as the final event in the process of natural death. Nevertheless, whilst the clinical decision may be clear, serious consideration needs to be given to discussion with the patient and family; this is covered in the section ‘Discussing CPR decisions’, below.

In many cases, including in palliative care, the benefits and burdens of CPR are less clear-cut. For example, in a patient with an ultimately palliative diagnosis but who is otherwise active and well, there is a small chance that CPR in the event of a cardiac arrest may succeed. It is beyond the remit of this work to outline factors that count for and against this. In such cases, the preferences of patients (or those delegated to make decisions on their behalf) are pivotal.

Discussing CPR decisions

As outlined above, discussing CPR decisions is not relevant in a large proportion of hospital patients, as presumption of consent exists. This section is concerned with those cases where cardiac arrest is a realistic possibility.

Further considerations

It is not possible to cover all eventualities for these decisions, and professional guidance exists and should be followed. Two further issues warrant discussion, however; managing unresolved disagreements and transfer to the home environment.

Despite the emotive nature of the subject and complexity of decisions, it is usually possible to work through DNACPR decisions to the agreement of the patient, their loved ones and the clinical team. As described above, a second opinion can be helpful in resolving a disagreement. Occasionally no agreement can be reached between doctor, the team, the patient and those close to the patient. In extreme cases, particularly where the patient lacks capacity, legal advice may be required and consideration given to more formal measures such as the involvement of the Court of Protection.

A further point to highlight is the transfer of DNACPR decisions to the home environment. In such context, the patient and their family/carers are responsible for the documentation and, as such, are able to ignore or withhold it if they wish. For this reason, clear communication and agreement in advance are vital.

Key points

• • Palliative care takes an holistic approach addressing physical,psychological, social and spiritual needs of the patient,their carers and family

• • Symptoms should be actively sought and treated in a pro active manner by the multidisciplinary team

• • Pain is very common, affecting most patients at some point and maybe disease or treatment related.

• • Constipation develops in half of patients who are terminally ill with cancer admitted to hospice

• • Confusion can affect up to 75% of cancer patients at some stage.

• • Spinal metastases should be considered where there is new or progressive back pain and investigated pro actively

• • A key role of the doctor is to recognise when death is imminent and should prompt a through review of all care and interventions with unnecessary medication being stopped.