End of life care in Head & Neck cancer
🕊️ End of life care in head & neck cancer is complex due to airway risk, bleeding, dysphagia, and communication difficulties.
⚠️ Priorities: comfort, airway safety, secretion control, and anticipatory planning.
💬 Early discussions with patient + family are essential (especially around catastrophic bleeding and airway compromise).
📖 Key Principles
- Focus on symptom control and dignity, not disease treatment
- Anticipate complications: airway obstruction, bleeding, aspiration
- Minimise interventions that increase burden
- Early involvement of specialist palliative care + MDT
🫁 Airway Management
- ⚠️ Risk of airway obstruction (tumour, oedema, secretions)
- Position patient upright where possible
- Consider:
- 💊 Dexamethasone → reduces tumour-related oedema
- 💊 Opioids → relieve dyspnoea
- 💊 Benzodiazepines → anxiety/panic from breathlessness
- 🚫 Avoid invasive airway interventions unless clearly appropriate
- Discuss ceiling of care (e.g. no intubation)
🩸 Catastrophic Bleeding (“Carotid Blowout”)
- Rare but life-threatening and distressing
- Risk factors: tumour erosion into vessels, prior radiotherapy
- 💡 Anticipatory planning:
- Dark towels (reduce visual distress)
- Crisis medications at bedside
- 💊 Midazolam (rapid sedation) ± opioid for distress
- Focus = rapid comfort, not resuscitation
💧 Secretions (“Death Rattle”)
- Due to impaired swallowing + airway clearance
- Repositioning (side lying)
- 💊 Antimuscarinics:
- Glycopyrronium
- Hyoscine butylbromide
- ❌ Avoid deep suction (distressing, limited benefit)
🍽️ Dysphagia & Nutrition
- Very common → aspiration risk
- Allow oral intake for comfort if safe
- Often stop enteral feeding in last days
- Good mouth care is essential 👄
😖 Pain Management
- Often severe (tumour invasion, nerve involvement)
- Follow WHO analgesic ladder
- ✔️ Strong opioids (e.g. morphine)
- ✔️ Consider adjuvants (neuropathic pain: gabapentin, amitriptyline)
- Alternative routes (SC syringe driver) if unable to swallow
🧠 Delirium & Anxiety
- Common (infection, hypoxia, metabolic causes)
- 💊 Haloperidol (first-line for delirium)
- 💊 Benzodiazepines if agitation/anxiety prominent
💬 Communication Issues
- Speech may be impaired (tumour, surgery, tracheostomy)
- Use:
- Writing tools / communication boards
- Family support
- Maintain dignity and inclusion in decisions
💉 Anticipatory Prescribing (UK Practice)
- Opioid → pain/dyspnoea
- Midazolam → anxiety/agitation
- Haloperidol → delirium/nausea
- Glycopyrronium → secretions
💡 Last Days of Life
- Stop non-essential medications
- Use syringe driver for symptom control
- Minimal monitoring
- Focus entirely on comfort + family support
🧠 Clinical Pearls (Exam + Real Life)
- Always consider risk of airway compromise in head & neck cancer
- “Carotid blowout” → prepare family + staff in advance
- Secretions are often more distressing for family than patient
- Communication impairment ≠ lack of capacity
- Think: anticipate, prescribe early, reduce crisis
