management of common symptoms in terminally ill patients

1. Slide 1 Junior Rotation in Hospice and Palliative Medicine Management of Common Symptoms in Terminally Ill Patients Junior Rotation in Hospice and Palliative Care

2. Slide 2 Junior Rotation in Hospice and Palliative Medicine

3. Slide 3 Junior Rotation in Hospice and Palliative Medicine General Approach to Symptom Management at End-of-Life Search for cause of symptom History, physical, laboratory (as appropriate) Treat underlying cause (if reasonable) Treat the symptom Re-evaluate frequently

4. Slide 4 Junior Rotation in Hospice and Palliative Medicine Fatigue

5. Slide 5 Junior Rotation in Hospice and Palliative Medicine Fatigue Most common symptom in medicine Lack of energy, tiredness Subjective weakness Diminished mental capacity Not relieved by rest May be incapacitating

6. Slide 6 Junior Rotation in Hospice and Palliative Medicine Diagnosis of Fatigue Often under diagnosed or ignored Multidimensional assessment tools available The Brief Fatigue Inventory (BFI)http://prg.mdanderson.org/bfi.pdf

7. Slide 7 Junior Rotation in Hospice and Palliative Medicine

8. Slide 8 Junior Rotation in Hospice and Palliative Medicine Pathogenesis of Fatigue Physical causes Decreased O2 carrying capacity: Anemia or CHF Cancer, chronic illnesses Treatments for cancer, HBP, other Psychological causes Anxiety and / or depression

9. Slide 9 Junior Rotation in Hospice and Palliative Medicine Erythropoietin and Fatigue in Terminal Illness May benefit selected patients Symptomatic anemia Low erythropoietin levels Considerations: Cost Time to effect (4 to 6 weeks)

10. Slide 10 Junior Rotation in Hospice and Palliative Medicine Palliative treatment of Fatigue Nonpharmacologic therapy Patient/family education: Permission to be tired Energy conservation strategies Pharmacologic therapy Dexamethasone 2-20 mg qAM Methylphenidate 2.5-5 mg qAM and noon Antidepressant trial (SSRI)

11. Slide 11 Junior Rotation in Hospice and Palliative Medicine Anorexia and Cachexia

12. Slide 12 Junior Rotation in Hospice and Palliative Medicine Anorexia and Cachexia in the end-of-life setting Wasting syndromes: Anorexia, weight loss, fatigue Cancer, chronic organ failure, chronic infections, AIDS. Treatable causes: Chronic pain Mouth conditions (dryness, mucositis, thrush, HSV) GI motility problems (e.g., constipation) Reflux esophagitis Treatments for cancer

13. Slide 13 Junior Rotation in Hospice and Palliative Medicine Management of Anorexia and Cachexia, cont�d� Hyperalimentation in cancer anorexia / cachexia syndromes: Increase in body fat, not protein Potential for harm � fluid overload, infections, aspiration Invasive Weigh benefit vs. burden

14. Slide 14 Junior Rotation in Hospice and Palliative Medicine Comfort Care for Terminally Ill Patients: The Appropriate Use of Nutrition and Hydration.RM McCann, WJ Hall, A Groth-Juncker. JAMA 1994 272: 1263-6. Patients generally did not experience hunger. Those who did needed only small amounts of food for alleviation. Thirst and dry mouth were relieved by mouth care and sips of liquid far less than needed to prevent dehydration. Food and fluid administration beyond the specific requests of patients may play a minimal role in providing comfort to terminally ill patients.

15. Slide 15 Junior Rotation in Hospice and Palliative Medicine Management of Anorexia and Cachexia Nonpharmacological therapy Patient and family education; ineffectiveness and discomfort of forced feeding/nutrition/hydration Replace caregiver �need to feed� with behaviors that alleviate symptoms� Eliminate dietary restrictions� eat p.r.n., in amount desired Reduce portion size, more frequent meals

16. Slide 16 Junior Rotation in Hospice and Palliative Medicine Management of Anorexia and Cachexia Pharmacologic therapy Dexamethasone 2 to 20 mg po qAM. Megesterol (Megace), 200 mg po q6-8 hrs, titrated to achieve desired effect. Dronabinol (Marinol) 2.5 mg po BID or TID; titrate dose to patient tolerance and desired effect. Androgens currently under investigation.

17. Slide 17 Junior Rotation in Hospice and Palliative Medicine Nausea and Vomiting

18. Slide 18 Junior Rotation in Hospice and Palliative Medicine Nausea and Vomiting Frequency in terminal cancer: Nausea--50% to 60% of patients Vomiting--30% of patients Can be controlled in 90% of cases

19. Slide 19 Junior Rotation in Hospice and Palliative Medicine Nausea and Vomiting � key organs involved� Brain Chemoreceptor trigger zone (CTZ) Cerebral cortex Vestibular apparatus Vomiting center Gastrointestinal tract

20. Slide 20 Junior Rotation in Hospice and Palliative Medicine Nausea and Vomiting � neurotransmitters involved� Serotonin Dopamine Acetylcholine Histamine

21. Slide 21 Junior Rotation in Hospice and Palliative Medicine Pathophysiology: Nausea and Vomiting

22. Slide 22 Junior Rotation in Hospice and Palliative Medicine Nausea and Vomiting:Some treatable causes Chemoreceptor Trigger Zone Drugs Metabolic � e.g., renal, liver, electrolyte: hyponatremia, hypercalcemia Cortical: Anticipatory nausea Learned responses Anxiety, uncontrolled pain

23. Slide 23 Junior Rotation in Hospice and Palliative Medicine Nausea and Vomiting:More treatable causes Vestibular Opioids trigger Ach-mediated nausea in vestibular apparatus Gastrointestinal Tract Gastritis/esophagitis Constipation, impaction Obstruction Drugs Tube feedings

24. Slide 24 Junior Rotation in Hospice and Palliative Medicine Management of Nausea and Vomiting

25. Slide 25 Junior Rotation in Hospice and Palliative Medicine Management of Nausea and Vomiting

26. Slide 26 Junior Rotation in Hospice and Palliative Medicine Metastases Meningeal irritation Movement Mental anxiety Medications Mucosal irritation Mechanical obstruction Motility Metabolic Microbes Myocardial M-Esis� the 11 M�s

27. Slide 27 Junior Rotation in Hospice and Palliative Medicine Management of Nausea and Vomiting

28. Slide 28 Junior Rotation in Hospice and Palliative Medicine Persistent nausea...in a terminally ill patient Start with Haloperidol 1 mg PO or SC bid or tid, increase to 10 to 15 mg/day, as needed If needed, add: Antihistamine (e.g., hydroxyzine) and /or Metoclopramide (beware in bowel obstruction) Other: Ondansetron (Zofran), Granisitron (Kytril), Dolasetron (Anzemet), methotrimeprazine (Levoprome), Aprepitant (Emend) - $300/dose

29. Slide 29 Junior Rotation in Hospice and Palliative Medicine Constipation, Bowel Obstruction

30. Slide 30 Junior Rotation in Hospice and Palliative Medicine Factors Affecting Bowel Movement Intestinal solids Stool water content Gastrointestinal motility Gastrointestinal lubrication

31. Slide 31 Junior Rotation in Hospice and Palliative Medicine Constipation: What makes us go�

32. Slide 32 Junior Rotation in Hospice and Palliative Medicine Constipating Drugs� Morphine Tricyclic antidepressants Scopolamine Diphenhydramine Vincristine Verapamil Other Ca++ channel blockers Iron Aluminum Calcium salts

33. Slide 33 Junior Rotation in Hospice and Palliative Medicine Bowel Obstruction...in advanced cancer Incidence � 3% overall in Hospice Ovarian Cancer: 5% to 42% Colorectal Cancer: 10% to 30% Mechanism: mechanical, paralytic Symptoms... Surgery...limited usefulness in terminally ill cancer patients

34. Slide 34 Junior Rotation in Hospice and Palliative Medicine Management of Bowel Obstruction in Terminally Ill Patients Surgery extremely poor risk Aggressive pain management Stool softeners, soft / liquid diet Manage nausea (Haldol, Benadryl) Octreotide

35. Slide 35 Junior Rotation in Hospice and Palliative Medicine Octreotide (SandostatinTM) Synthetic analogue of Somatostatin: Decreases intestinal secretion, bile flow Increases intestinal absorption Adverse effects: Dry mouth, Flatulence Hypo- or hyperglycemia Pain at injection site... Dosage and administration 150 mg SC, bid OR 300 mg over 24h by SC infusion. Max. 600 mg/day

36. Slide 36 Junior Rotation in Hospice and Palliative Medicine Delirium

37. Slide 37 Junior Rotation in Hospice and Palliative Medicine Delirium and terminal agitation Delirium: up to 85% of terminal cancer patients Features may include Clouding of consciousness, altered attention Perceptual disturbances Acute onset, fluctuating course � distinguish from dementia

38. Slide 38 Junior Rotation in Hospice and Palliative Medicine Delirium--Causes D Drugs, especially psychotropics E Electrolyte imbalance L Liver failure I Ischemia or hypoxia R Renal failure I Impaction of stool U Urinary tract or other infection M Metastases, other neurological

39. Slide 39 Junior Rotation in Hospice and Palliative Medicine Drug Treatment of Delirium Haloperidol 1-2 mg PO or SC q1h to calm the crisis, then q6-12 hr If more sedation is desired, or for the AIDS dementia complex, use Thioridazine (Mellaril) 25-50 mg PO q1h until calm then q6-12 hr OR Chlorpromazine 25-50 mg PO or IV until calm then q6-12 hr

40. Slide 40 Junior Rotation in Hospice and Palliative Medicine Severe Agitated Delirium Consider ADDING Chlorpromazine (Thorazine) 100 mg q1h PO, PR or IV until calm Midazolam (Versed) 0.4-4 mg/hr continuous SC or IV infusion Lorazepam (Ativan) 1-2 mg q1hr until calm (PO, SL or IV)

41. Slide 41 Junior Rotation in Hospice and Palliative Medicine Dyspnea

42. Slide 42 Junior Rotation in Hospice and Palliative Medicine Breathlessness (dyspnea) . . . May be described as shortness of breath a smothering feeling inability to get enough air suffocation

43. Slide 43 Junior Rotation in Hospice and Palliative Medicine . . . Breathlessness (dyspnea) The only reliable measure is patient self-report Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness Prevalence in the terminally ill: 12 � 74%

44. Slide 44 Junior Rotation in Hospice and Palliative Medicine Causes of breathlessness Anxiety Airway obstruction Bronchospasm Hypoxemia Pleural effusion Pneumonia Pulmonary edema Pulmonary embolism Thick secretions Anemia Metabolic Family / financial / legal / spiritual / practical issues

45. Slide 45 Junior Rotation in Hospice and Palliative Medicine Managementof breathlessness Treat the underlying cause Symptomatic management oxygen opioids anxiolytics nonpharmacologic interventions

46. Slide 46 Junior Rotation in Hospice and Palliative Medicine Oxygen Potent symbol of medical care Fan may do just as well Expensive Pulse oximetry not helpful

47. Slide 47 Junior Rotation in Hospice and Palliative Medicine Opioids Small doses � titrate to get desired relief of symptom without side effects Relief not related to respiratory rate Central and peripheral action

48. Slide 48 Junior Rotation in Hospice and Palliative Medicine Anxiolytics Safe in combination with opioids lorazepam 0.5-2 mg po q 1 h prn until settled then dose routinely q 4�6 h to keep settled

49. Slide 49 Junior Rotation in Hospice and Palliative Medicine Nonpharmacologic interventions . . . Reassure, work to manage anxiety Behavioral approaches, eg, relaxation, distraction, hypnosis Limit the number of people in the room Open window

50. Slide 50 Junior Rotation in Hospice and Palliative Medicine Nonpharmacologic interventions . . . Eliminate environmental irritants Keep line of sight clear to outside Reduce the room temperature but avoid chilling the patient

51. Slide 51 Junior Rotation in Hospice and Palliative Medicine . . . Nonpharmacologic interventions Introduce humidity Reposition elevate the head of the bed Sit with arms up on pillow on a table Educate, support the family

52. Slide 52 Junior Rotation in Hospice and Palliative Medicine General Approach to Symptom Management at End-of-Life Search for cause of symptom History, physical, laboratory (as appropriate) Treat underlying cause (if reasonable) Treat the symptom Re-evaluate frequently

53. Slide 53 Junior Rotation in Hospice and Palliative Medicine

54. Slide 54 Junior Rotation in Hospice and Palliative Medicine Resources End-of-life Physicians Education Resource Center http://www.eperc.mcw.edu Education for Physicians on End-of-life Care http://www.epec.net

55. Slide 55 Junior Rotation in Hospice and Palliative Medicine More Resources�Palliative Care Consult Service Palliative care beeper 8-BEEP, #1809 Team members: Nurses: Patricia Roberts, Dianne Pannullo Social Worker: Jeanne Trask Chaplain: Caroline Silva Medical Director: Timothy Keay