Palliative emergencies • Rapid assessment • Reversible crises • Comfort-focused care • Last 48 hours

Identification and Management of Palliative-Care Emergencies

An emergency-medicine guide to spinal cord compression, hypercalcaemia, dyspnoea, bleeding, seizures, obstruction and the terminal phase

Learning objectives

• Define a palliative emergency and distinguish reversible emergencies from expected terminal changes.
• Recognize red flags for spinal cord compression, hypercalcaemia, superior vena cava obstruction, haemorrhage, tumour lysis, seizures, neutropenic fever, raised intracranial pressure, urinary retention and bowel obstruction.
• Apply an initial-contact, hospital, nursing, medication and follow-up plan for each crisis.
• Use proportionate treatment that respects goals of care, consent, capacity, family needs and the patient’s preferred place of care.
• Provide comfort-focused care during the last 48 hours, including mouth, skin, secretion, breathing, agitation, hydration and family support.

1. What is a palliative emergency?

A palliative emergency is a sudden or rapidly worsening problem that threatens life, function, comfort, dignity or the ability to remain in a preferred place of care. It may be caused by the underlying disease, treatment toxicity, a medication error or an unrelated acute illness. Some emergencies require urgent disease-modifying treatment; others are managed primarily for comfort when burdens outweigh benefits.

2. Severe sudden pain or an acute pain crisis

Recognition

• A sudden change from baseline, pain out of proportion, new neurological or vascular findings, guarding, shock, fever, vomiting, bleeding or a new injury.
• Common causes include vertebral collapse, pathological fracture, biliary/ureteric spasm, bladder spasm, obstruction, infection, haemorrhage and medication withdrawal.

Management

1. ABCDE, urgent focused examination and a validated pain score at rest and movement.
2. Position and immobilize a suspected fracture or unstable spine; obtain urgent imaging and specialist review.
3. Give monitored analgesia according to the patient’s existing opioid exposure and local protocol. The supplied reference advises reassessment after approximately 20 minutes for subcutaneous, 5 minutes for intravenous and 40 minutes for oral dosing; follow the actual medicine’s onset and local protocol.
4. Do not keep increasing opioids without reviewing renal failure, opioid-induced hyperalgesia, constipation, obstruction or a new diagnosis.
5. For suspected biliary/ureteric spasm, investigate the cause; an NSAID may be considered when renal, gastrointestinal, cardiovascular and bleeding risks permit, with opioid support if needed.
6. Document the crisis, treatment, response, functional goal and escalation plan.

3. Acute dyspnoea and breathlessness

Breathlessness is frightening for patients and families. Causes include infection, pulmonary oedema, embolism, pleural effusion, airway obstruction, anaemia, metabolic disease, anxiety, tumour progression and opioid toxicity.

Immediate assessment and first aid

• Assess airway, respiratory effort, oxygen saturation, chest movement, consciousness, fever, pain and circulation.
• Sit the patient upright or in the most comfortable position; stay with them and explain each action.
• Increase airflow over the face using a fan or open window if safe and acceptable.
• Give oxygen for documented hypoxaemia or a clear clinical indication; do not force a mask on a distressed patient without explanation.
• Treat reversible causes: antibiotics for infection, pleural drainage for a large symptomatic effusion, diuresis for pulmonary oedema, bronchodilation for bronchospasm, steroids for selected obstruction and urgent specialist care for embolism or pneumothorax.

Medication and monitoring

• Low-dose morphine may reduce the sensation of refractory breathlessness; the supplied slide gives 2.5–5 mg every 4 hours as an educational example, with cautious increments for a patient already receiving morphine. Confirm opioid exposure, respiratory status, renal function and local protocol.
• A benzodiazepine may help severe anxiety or panic after reversible causes and respiratory depression have been assessed. The supplied slide lists diazepam 2.5–10 mg twice daily; current palliative protocols vary and additive opioid sedation is a major risk.
• Monitor respiratory rate/effort, sedation, oxygenation, anxiety, response and family distress. Escalate sudden severe breathlessness, stridor, cyanosis, shock or altered consciousness.

4. Malignant spinal cord compression (MSCC)

MSCC is an oncological emergency. The supplied references note that about 5% of people with advanced cancer develop compression, commonly from breast, lung, myeloma and prostate cancer; lower thoracic vertebrae are frequently involved. Early disease may present with pain before neurological signs.

Red flags

• New or worsening central back pain, especially night pain, pain aggravated by movement, cough, strain or lying flat.
• Radicular pain, unsteadiness, difficulty climbing stairs, weakness, numbness or a sensory level.
• Urinary hesitancy, retention, incontinence, constipation or reduced anal tone.
• Spastic paresis, increased reflexes and upgoing plantars above the cauda equina; flaccid weakness, absent reflexes and dermatomal changes with cauda equina compression.

Immediate management

1. Immobilize and handle carefully if instability or fracture is possible; assess neurological function and bladder/bowel status repeatedly.
2. Call oncology, neurosurgery/orthopaedics, radiology and palliative teams. Obtain urgent MRI where available; CT is an alternative when MRI is not possible.
3. Give corticosteroid only according to current protocol. The supplied slides describe dexamethasone 10 mg IV stat followed by 4 mg every 6 hours, while other protocols use a total 16–24 mg/day; verify the current regimen and monitor glucose, infection, delirium and gastrointestinal risk.
4. Provide strong analgesia, pressure care, thrombosis/falls precautions and bladder management.
5. Definitive options include radiotherapy, surgery for selected instability/compression or tissue diagnosis, chemotherapy for chemosensitive tumours and rehabilitation.
6. Ambulation at presentation is an important prognostic factor; early recognition protects mobility and comfort.

5. Hypercalcaemia of malignancy

Hypercalcaemia may result from parathyroid-hormone-related peptide, tumour osteoclast activation or increased vitamin-D activity. It is associated with myeloma, breast, renal and lung cancers and lymphoma, but may occur without obvious bone metastases.

Clinical features

• Nausea, anorexia, vomiting, constipation, abdominal pain, thirst, polyuria, dehydration and worsening bone pain.
• Weakness, drowsiness, confusion, ataxia, seizures, coma and cardiac arrhythmia.

Management

1. Confirm calcium (correct for albumin or use ionized calcium where available), renal function, hydration, ECG and reversible contributors.
2. If mild and asymptomatic, encourage oral fluids where safe, review medicines and consider specialist oral bisphosphonate treatment.
3. If symptomatic or markedly elevated, provide monitored IV isotonic saline; the supplied slide describes 2–4 L over 24 hours, but adjust for heart/renal failure, age and fluid status.
4. Use IV bisphosphonate under specialist/local protocol; an educational example is pamidronate 60–90 mg as a single infusion over 2–24 hours. Monitor renal function, calcium and fluid balance.
5. Consider corticosteroid for myeloma or lymphoma-related hypercalcaemia and specialist calcitonin/denosumab where indicated.
6. Escalate severe arrhythmia, coma, renal failure, seizures or inability to hydrate; dialysis may be required in selected cases.

6. Superior vena cava obstruction (SVCO)

SVCO results from extrinsic compression, intraluminal thrombosis or invasion of the vessel wall, commonly from lung cancer or mediastinal lymphoma.

Features

• Dyspnoea, facial/neck/arm swelling, engorged jugular veins, chest-wall collaterals, plethora, cyanosis, cough, dysphagia, headache and a feeling of head fullness.
• Vocal-cord paresis, Horner syndrome, cognitive change, hallucinations, seizures, stridor, coma or death in severe cases.

Management

1. Sit the patient upright, assess airway and breathing, provide oxygen if hypoxaemic and avoid unnecessary supine positioning or upper-limb venous access when possible.
2. Urgently assess for laryngeal oedema, cerebral symptoms, thrombus, respiratory failure and the patient’s goals.
3. Obtain tissue diagnosis and staging when clinically appropriate; treatment may be chemotherapy for lymphoma or radiotherapy for lung/mediastinal disease.
4. Symptomatic measures may include dexamethasone (the supplied slide lists 16 mg/day), opioids for dyspnoea, carefully selected anxiolysis and diuresis. Verify diagnosis, contraindications and protocol.
5. Severe stridor, neurological deterioration or airway compromise requires emergency specialist intervention.

7. Haemorrhage and haemoptysis

Recognition

Bleeding may be external, gastrointestinal, urinary, vaginal, airway or internal. Watch for sudden pallor, weakness, tachycardia, hypotension, confusion, melena, haematemesis, haematuria, coughing blood or a rapidly bleeding tumour.

Management

• Call help, assess ABCDE, protect the airway and use calm, honest communication.
• Review anticoagulants and antiplatelets; stop or reverse only according to senior/local protocol and goals.
• Stop NSAIDs when gastrointestinal bleeding is suspected; consider gastroprotection and resuscitation when consistent with goals.
• Use dark towels/sheets to reduce visual distress, provide privacy and do not leave the patient alone.
• Seek radiology, surgery, oncology or endoscopy for a reversible source. Radiotherapy may help bleeding tumours.
• For recurrent minor bleeding, tranexamic acid may be considered under protocol; the supplied slide gives 1 g four times daily. Topical agents require trained application and airway/skin safety.
• A catastrophic terminal haemorrhage may require rapid symptom relief, family support and proportionate sedation under specialist guidance rather than burdensome transfer.

8. Tumour lysis syndrome

Tumour lysis syndrome can follow rapid tumour cell breakdown, releasing potassium, phosphate and urate and causing hypocalcaemia, acute kidney injury, arrhythmia, seizures and death. It is most associated with highly chemosensitive, bulky haematological malignancy, but can occur spontaneously.

• Assess: nausea, vomiting, weakness, cramps, oliguria, confusion, seizures and arrhythmia; check electrolytes, urate, creatinine, phosphate, calcium and ECG.
• Prevent: risk-stratified hydration and allopurinol before treatment when appropriate; specialist protocols may use rasburicase for high risk or established hyperuricaemia.
• Treat: monitored fluids, electrolyte correction, nephrology/oncology review and dialysis for refractory renal failure, potassium or fluid overload. Avoid routine urinary alkalinization unless directed by a specialist protocol.
• Do not give potassium, phosphate or calcium casually without laboratory and ECG guidance.

9. Seizures

1. Protect from injury, place in a safe lateral position when possible, time the seizure, assess airway/breathing and check glucose.
2. Look for hypoglycaemia, electrolyte disturbance, infection, raised intracranial pressure, medication toxicity, withdrawal or brain metastasis.
3. Use a benzodiazepine according to the emergency protocol; the supplied slide lists diazepam 10–20 mg as an example, but route and current local regimen must be confirmed.
4. For recurrent seizures, involve neurology/palliative teams for maintenance anticonvulsant therapy. Phenytoin has major interactions and enzyme-inducing effects; do not start prophylaxis routinely without a defined indication.
5. After the event, assess aspiration, injury, recovery, family distress and the patient’s goals.

10. Neutropenic fever

Neutropenic fever is a time-critical infection emergency in a patient receiving or recently receiving anticancer treatment. Fever may be the only sign.

• Perform ABCDE, obtain cultures and blood tests without delaying treatment, assess line, chest, urine, skin, mouth, abdomen and perianal area.
• Start empirical broad-spectrum antibiotics promptly according to the current local guideline and allergy/renal status. The supplied slide mentions cephalosporin-based combinations but older regimens are not universal; do not copy them.
• Give fluids, oxygen, antipyretic comfort care and source control as indicated.
• Escalate shock, hypoxia, altered consciousness, severe mucositis, abdominal pain or rapidly worsening illness to senior/oncology/ICU care.

11. Raised intracranial pressure and brain metastases

• Red flags: headache with vomiting, papilloedema, altered consciousness, focal deficit, seizures, bradycardia/hypertension pattern or abnormal pupils.
• Elevate the head modestly, maintain oxygenation and avoid fever, hypoglycaemia and hypotension.
• Dexamethasone is commonly used for symptomatic vasogenic edema under a specialist protocol; monitor glucose, infection, mood and muscle weakness.
• Mannitol or hypertonic therapy and controlled ventilation are ICU interventions for impending herniation—not routine palliative measures. The supplied slides mention mannitol 1–1.5 g/kg; current critical-care guidance and senior oversight are essential.
• Arrange urgent imaging, neurosurgical/oncology review and radiotherapy where appropriate, or comfort-focused care if that matches goals.

12. Acute urinary retention and bladder spasm

• Assess lower abdominal discomfort, palpable bladder, urine output, catheter kinking/blockage, constipation, medicines, infection, clots, prostate disease and neurological compression.
• Catheterize when indicated and authorized; clot retention may require bladder washout by trained staff.
• Treat infection, tumour, constipation or mechanical causes. Alpha-blockers may help selected prostatism but can cause postural hypotension.
• Bladder spasm may respond to cause-directed treatment, anticholinergics, NSAIDs where safe, or specialist options. The supplied slides list examples such as amitriptyline, propantheline, hyoscine, naproxen, diazepam and dexamethasone; verify current local protocols and avoid stacking anticholinergic/sedating agents.
• Monitor pain, urine output, haematuria, infection, catheter trauma and dignity.

13. Intestinal obstruction

Obstruction may be partial or complete and can result from tumour, adhesions, hernia, constipation, volvulus or treatment. Peritoneal metastases may create multiple levels where surgery is not feasible.

• Assess pain pattern, distension, vomiting, stool/flatus, hydration, electrolytes, peritonism and goals.
• Urgently involve surgical and palliative teams; investigate when results will alter care.
• Use analgesia, antiemetic, antisecretory/antispasmodic medicines and corticosteroid when indicated; review the oral route.
• Consider nasogastric decompression, stenting, venting procedure or surgery in selected patients.
• Avoid bulk laxatives and prokinetics in complete obstruction. Provide mouth care and clear family communication.

14. The last 48 hours of life

The terminal phase is marked by day-to-day deterioration in strength, appetite, fluid intake and awareness. Signs may include increasing weakness, bed-bound status, reduced food/fluid intake, difficulty swallowing and reduced consciousness. The goals change from burdensome disease modification to comfort, dignity, communication and preparation—while still treating distressing reversible causes when consistent with the patient’s wishes.

14.1 Communication and goals

• Explain expected changes using plain language and allow questions, silence and cultural rituals.
• Confirm who the patient wants present, preferred place of care and emergency limits.
• Stop non-essential investigations and medicines; convert essential oral medicines to a suitable route when swallowing fails.
• Tell the family clearly when death occurs and provide bereavement support.

14.2 Symptom and nursing care

Problem	Comfort-focused care
Weakness/fatigue	Gentle assistance with activities, do not hurry, cluster essential care, stop non-essential observations and prevent falls.
Secretions (“death rattle”)	Reassure family that noisy pooled secretions are often more distressing to hear than to the patient; reposition, provide mouth care and avoid repeated deep suctioning.
Pain	Use facial expression, sweating, movement and caregiver report when drowsy; continue appropriate analgesia by a feasible route and assess total pain.
Agitation	Look for pain, full bladder/rectum, hypoxia, infection, withdrawal and medicines; reduce stimulation, involve family and seek specialist medication advice.
Incontinence	Prompt cleansing, pads or catheter when beneficial, barrier protection and dignity.
Breathing changes	Position comfortably, explain irregular patterns, provide calm presence and prescribed breathlessness relief; oxygen is not automatically required.
Oral dryness	Frequent moist mouth care, lip balm, clean dentures and remove them when drowsy if appropriate; offer ice chips only when swallowing is safe.
Skin	Reposition for comfort rather than rigid schedules, gentle cleansing, pressure-relieving surfaces and incontinence care.
Hydration/nutrition	Explain that reduced intake is part of dying, not the cause of death; offer small sips if safe, moisten lips and avoid forced feeding or fluids that cause distress.

Specialist palliative sedation may be considered for refractory suffering after careful assessment, consent/decision-making and documentation. It is not the same as euthanasia and should never be used as a substitute for basic care or communication.

15. Nursing and team checklist

• Identify the emergency and record time of onset, baseline function, goals and advance decisions.
• Assign one clinician to stabilization and one to patient/family communication when staff allow.
• Use a symptom tool, document vital signs, neurological status, urine, bowel, medicines and response.
• Check allergies, renal/hepatic function, recent chemotherapy, anticoagulants, opioids and sedatives.
• Give prescribed emergency medicines with independent dose/concentration checks and continuous reassessment.
• Protect privacy, dignity, cultural practice and safe family involvement.
• Document referrals, decision-makers, treatment limits, uncertainty and review time.

16. Clinical cases

17. Quick self-test

1. What are the first universal steps in a palliative emergency?
2. Name four red flags for spinal cord compression.
3. List common symptoms of malignant hypercalcaemia.
4. How should acute dyspnoea be approached in a palliative patient?
5. What are the main comfort measures in the last 48 hours?
6. Why should deep suctioning usually be avoided for terminal secretions?

Answers

1. Call help, perform ABCDE, clarify goals/capacity without delaying care, relieve distress, identify reversible causes, treat, reassess and document.
2. New night back pain, movement/cough pain, unsteadiness, weakness, numbness, sensory level, urinary retention/incontinence, constipation or reduced anal tone.
3. Nausea, anorexia, vomiting, constipation, thirst, polyuria, dehydration, weakness, drowsiness, confusion, ataxia, seizures, coma and arrhythmia.
4. ABCDE, upright position, calm presence, airflow/fan, oxygen when indicated, treat reversible causes, use carefully monitored symptom medicines and escalate sudden severe distress.
5. Comfortable positioning, mouth and skin care, symptom medicines by feasible route, privacy, communication, family support, safe toileting, non-forced intake and preparation for death.
6. Secretions are often more distressing to hear than to the patient; deep suction can cause trauma, bleeding and distress without improving comfort.

Key take-home points

• Palliative emergencies demand rapid clinical assessment and compassionate communication at the same time.
• MSCC, hypercalcaemia, SVCO, haemorrhage, tumour lysis, seizures, neutropenic fever and raised intracranial pressure can be life-threatening but may be treatable.
• Analgesia and symptom relief continue while investigations and definitive treatment occur.
• In the last 48 hours, comfort, dignity, mouth/skin care, positioning, family preparation and goal-concordant treatment take priority.
• Use supplied doses only as educational examples; current Uganda protocols and specialist advice govern real prescribing.

Further study and references

• Palliative Care Emergencies — supplied Slideshare reference
• Emergencies in Palliative Care and the Last 48 Hours — supplied Slideshare reference
• WHO: Palliative care
• Uganda Clinical Guidelines 2023
• Related lesson: Principles of symptom control and assessment
• Related lesson: Oral morphine safety and Uganda’s legal framework

Educational resource for supervised learning. Apply current Uganda emergency, oncology and palliative-care protocols and seek senior support for all high-risk decisions.