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Clinical Review

ABC of palliative care: Emergencies

BMJ 1997; 315 doi: (Published 06 December 1997) Cite this as: BMJ 1997;315:1525
  1. Stephen Falk,
  2. Marie Fallon


    The concept of rapid assessment, evaluation, and management of symptoms due to malignancy is generally accepted. Inherent in this concept is rapid reversal of what is reversible. Some acute events in malignancy have to be treated as an emergency if a favourable outcome is to be achieved. As in any emergency, the assessment must be as prompt and complete as possible. In patients with advanced malignancy, factors to consider include.

    While unnecessary hospital admission may cause distress for the patient and carers, missed emergency treatment of reversible symptomatology can be disastrous.

    • The nature of the emergency

    • The general physical condition of the patient

    • Disease status and likely prognosis

    • Concomitant pathologies

    • Symptomatology

    • The likely effectiveness and toxicity of available treatments

    • Patients' and carers' wishes.

    Major emergencies in palliative care

    • Hypercalcaemia

    • Superior venal caval obstruction

    • Spinal cord compression

    • Bone fractures

    Other emergencies, such as haemorrhage and acute anxiety and depression, are discussed elsewhere in this series

    Questions to ask when considering management of emergencies in patients with advanced disease

    • What is the problem?

    • Can it be reversed?

    • What effect will reversal of the symptom have on patient's overall condition?

    • What is your medical judgment?

    • What does the patient want?

    • What do the carers want?

    • Could active treatment maintain or improve this patient's quality of life?


    Hypercalcaemia is the commonest life threatening metabolic disorder encountered in patients with cancer. The incidence varies with the underlying malignancy, being most common in multiple myeloma and breast cancer (40-50%), less so in non-small cell lung cancer, and rare in small cell lung cancer and colorectal cancer.

    Presenting features of hypercalcaemia

    Mild symptoms
    • Nausea

    • Anorexia and vomiting

    • Constipation

    • Thirst and polyuria

    Severe symptoms and signs
    • Gross dehydration

    • Drowsiness

    • Confusion and coma

    • Abnormal neurology

    • Cardiac arrhythmias

    It is important to remember non-malignant causes of hypercalcaemia—particularly primary hyperparathyroidism, which is prevalent in the general population.

    The pathology of hypercalcaemia is mediated by factors such as parathyroid related protein, prostaglandins, and local interaction by cytokines such as interleukin …

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