Dyspnea in Palliative Care of Children

1. Dyspnea in Palliative Care of Children Mike Harlos MD, CCFP Medical Director, WRHA Palliative Care and St. Boniface General Hospital Palliative Care Section Head, Palliative Care, University of Manitoba Dept. of Family Medicine

3. DYSPNEA: An uncomfortable awareness of breathing

4. DYSPNEA: “...the most common severe symptom in the last days of life” Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 - 98

5. Symptoms At The End of Life in Children With Cancer Hongo T. et al, Pediatrics International Feb 2003 p.60

6. Symptoms At The End of Life in Children With Cancer Wolfe J. et al, NEJM 2000; 342(5) p 326-333

7. End-of-Life Care in Cystic Fibrosis:Treatments Received in Last 12 Hours of Life Robinson,WM et al, Pediatrics 100(2) Aug.1997 Only 11% were noted to have titration of opioids at end of life specifically for dyspnea

8. HOW WELL ARE WE TREATING DYSPNEA IN THE TERMINALLY ILL? Addington-Hall JM, MacDonald LD, Anderson HR, Freeling P. Dying from cancer: the views of bereaved family and friends about the experience of terminally ill patients.Palliative Medicine 1991 5:207-214. • n = 80 Last week of life • severe / very severe dyspnea: 50% • less than ½ of these were offered • effective treatment

9. Causes of Dyspnea in Cancer Patients • Direct tumor effects • Indirect tumor effects • Treatment-related • Unrelated to cancer

10. DIRECT TUMOR CAUSES • Parenchymal • Lymphangitic carcinomatosis • Obstruction • Pleural effusion / tumor • Pericardial effusion • Superior vena cava obstruction • Ascites, hepatomegaly • Tumor microemboli

11. INDIRECT CANCER CAUSES • Cachexia, respiratory muscle atrophy • Mineral & electrolyte imbalances • Infections • Anemia • Pulmonary embolism • Neurologic paraneoplastic syndromes • Aspiration

12. Cancer Treatment-Related Causes Of Dyspnea • Surgery • Radiation pneumonitis / fibrosis • Chemotherapy-induced pulm. fibrosis (bleomycin) • Chemotherapy-induced cardiomyopathy • (adriamycin, cyclophosphamide) • Neutropenic infection

13. Approach To The Dyspneic Palliative Patient • Two basic intervention types: • Non-specific, symptom-oriented • Disease-specific

14. Simple Non-Specific Measures In Managing Dyspnea • calm reassurance • patient sitting up / semi-reclined • open window • fan

15. Non-Specific Pharmacologic Interventions In Dyspnea • Oxygen - hypoxic and ? non-hypoxic • Opioids - complex variety of central effects • Chlorpromazine - some evidence in adult literature; caution in children due to potential for dystonic reactions • Benzodiazepines - literature inconsistent but clinical experience extensive and supportive

16. TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE • Anti-tumor: chemo/radTx, hormone, laser • Infection • Anemia • CHF • SVCO • Pleural effusion • Pulmonary embolism • Airway obstruction

17. DISEASE-SPECIFIC MEDICATIONS FOR DYSPNEA • Corticosteroids • obstruction: SVCO, airway • lymphangitic carcinomatosis • radiation pneumonitis • Furosemide • CHF • lymphangitic carcinomatosis • Antibiotics • Anticoagulation– pulm. embolus • Bronchodilators • Transfusion

18. Opioids in Dyspnea • Uncertain mechanism • Often patient already on opioids for analgesia; if dyspnea develops it will usually drive the titration • Dosage should be titrated empirically; may easily reach doses commonly seen in adults • May need rapid dose escalation in order to keep up with rapidly progressing distress

19. Opioids and Sedatives in Dyspnea * Cancer Pain Relief and Palliative Care in Children, W.H.O. 1998 ¥ The Rainbows Children’s Hospice Guidelines 2002 ‡ Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack

20. Management of Terminal Secretions • Avoid deep suctioning… tends to cause increased secretions • “if you can see it, you can suction it” • Sometimes (approx. 5%) – it is not possible to completely relieve the secretions • Patient not likely to be aware of secretions when unresponsive and near death; family may need support in realizing this

21. Management of Terminal Secretions ctd

22. A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS How do you know that the aggressive use of opioids doesn't actually bring about or speed up the patient's death?

23. SUBCUTANEOUS MORPHINE IN TERMINAL CANCER Bruera et al. J Pain Symptom Manage. 1990; 5:341-344

24. Typically, with excessive opioid dosing one would see: • pinpoint pupils • gradual slowing of the respiratory rate • breathing is deep (though may be shallow) and regular

25. COMMON BREATHING PATTERNS IN THE FINAL HOURS Cheyne-Stokes Rapid, shallow “Agonal” / Ataxic

26. DOCTRINE OF DOUBLE EFFECT Wilkinson J. Oxford Textbook of Palliative Medicine 1993: p 497-8 Where an action, intended to have a good effect, can achieve this effect only at the risk of producing a harmful/bad effect, then this action is ethically permissible providing: • The action is good in itself. • The intention is solely to produce the good effect (even though the bad effect may be foreseen). • The good effect is not achieved through the bad effect. • There is sufficient reason to permit the bad effect (the action is undertaken for a proportionately grave reason).

27. Burdens Benefits Beneficial Effects Side Effects Mount B., Flanders E.M.; Morphine Drips, Terminal Sedation, and Slow Euthanasia: Definitions and Fact, Not AnecdotesJ Pall Care 12:4 1996; p 31-37 The principle of double effect is not confined to end-of-life circumstances Good effects Bad effects

28. The difference in aggressive opioid use in end-of-life circumstances is that the “bad effect” = Death • The doctrine of double effect exists to support those health care providers who may otherwise withhold opioids in the dying out of fear that the opioid may hasten the dying process • A problem with the emphasis on double effect is that there in an implication that this is a common scenario…. in day-to-day palliative care it is extremely rare to need to even consider its implications