Background Hypercalcaemia of malignancy is a common problem within the palliative population, which can cause distressing symptoms. It is a potentially reversible cause for deterioration which, if untreated, could lead to significant morbidity or mortality. Conventionally, treatment involves being transported as an emergency to hospital (or a hospice) to be admitted for intravenous (IV) fluids over several days followed by treatment with an IV bisphosphonate. Recovery may be uncertain. The community IV team and palliative care teams in central Manchester developed a collaborative standard operating procedure (SOP) for giving subcutaneous fluids to patients followed by IV zoledronic acid in their own home as means to try and keep vulnerable patients at home by avoiding unnecessary hospitalisation.

Methods A literature review was undertaken initially to establish best evidence-based practice. The SOP was prepared using quality improvement methodology and after discussion at clinical governance meetings. A patient information leaflet was written. Education sessions were delivered by the palliative care consultant. Clinical leads agreed treatment on a case-by-case basis for patients after a comprehensive assessment by palliative care teams.

Results To date 3 patients have been treated. All had improved symptom control. Patients and families reported that they had a better quality of life as they could be treated at home. Two achieved normocalcalcaemia without any adverse effects. One patient had repeated treatments for several months with good symptom control including improvements in pain and delirium. One patient was agitated and died despite treatment before the effects of the zoledronic acid would have been apparent.

Conclusion For frail patients approaching the terminal phases of their illness having treatment at home is potentially beneficial to both the patients, people important to them and has cost saving benefits due to admission avoidance. There is a plan to ratify the SOP for wider use within Manchester.