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Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms

Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms . Mike Marschke, MD. Mr. M - Chronic Smoker. Mr. M, 78 YO, is a lifetime smoker. Dyspnea began 5 years ago. intubated twice in the past year.

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Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms

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  1. Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms Mike Marschke, MD

  2. Mr. M - Chronic Smoker • Mr. M, 78 YO, is a lifetime smoker. Dyspnea began 5 years ago. • intubated twice in the past year. • Since last admission 2 mos ago always needs 2-3 l/min nasal cannula oxygen, even at rest. • He has lost 15 lbs, has a persistent cough, with gray phlegm • He is on steroids and nebulizers

  3. What is Dyspnea? • Subjective sense that you need to breath, that you ‘hunger air.’ • Mechanism • Respiratory Center of Medulla • Chemo receptors sensing low O2, hi CO2 • Mechano receptors (J receptors) in lung, respiratory muscles, and diaphragm • Vascular congestion-CHF • Cerebral Cortex

  4. Measurements? • pO2, pCO2, O2 sats • Peak flows • Pulmonary function tests measuring lung volumes and flow Prognosis < 6 mos. : • Class IV respiratory failure (= dyspnea at rest) • Frequent ER/hospital stays, recurring pulmonary infections, intubations • pO2 < 56mmHg, O2 sat < 89%, pCOs >50

  5. Dr. arrives • Mr. K is sitting in a reclining chair. • Feels “breathless” with minimal exertion. • Breathing is “heavy and suffocating”. • No apparent precipitating infection etc.

  6. Evaluation • Physical exam- distant breath sounds, coarse crackles at bases bilaterally, RR = 32 at rest, takes breathes in mid-sentence. • tachycardic at 100/min • Recent Weight loss of 15lbs. in 6 months. • 2+ edema bilateral lower extremities

  7. The Bargainer • Has no wish to be “brutalized”. He knows his emphysema will kill him someday. • He has executed a DNR • He wants to feel better but does not want to go back into the hospital. • What about CXR, labs?

  8. Assess cause • Complete assessment – may lead to treatable condition. • Pleural effusion • Pneumothorax • Anemia • PE • CHF • Pneumonia

  9. CXR Findings • Mass occluding R bronchus • Post obstruction atelectasis • Treatment options • Bronchoscopy • Radiation • Supportive • Weigh risk/benefits and patient wishes

  10. Oxygen • Pulse oximetry not helpful – go on symptoms • Potent symbol of medical care • Expensive, noisy, hot, uncomfortable for some • Fan may do just as well

  11. Opioids • Relief not related to respiratory rate • No ethical or professional barriers • Small doses • Central and peripheral action • Inhaled morphine works peripherally but may induce bronchospasm

  12. 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

  13. Nonpharmacologic interventions . . . • Reassure, work to manage anxiety • Behavioral approaches, eg, relaxation, distraction, hypnosis • Other CAM – aromatherapies (Eucalyptus, Bergomot), massage, healing touch • Limit the number of people in the room • Open window

  14. Nonpharmacologic interventions . . . • Eliminate environmental irritants • Keep line of sight clear to outside • Reduce the room temperature • Avoid excessive temperatures

  15. . . . Nonpharmacologic interventions • Introduce humidity • Reposition • elevate the head of the bed • move patient to one side or other • Educate, support the family

  16. 4 Weeks Later in Hospice • More dyspneic and semi-comatose • Lots of upper airway noise with wheezes more prevalent • Gets agitated at times, cyanotic • Difficult swallowing pills • At times when sleeping family feels he is choking to death

  17. Final hours of care • Educate the family- no surprises • Double effect? • Oral secretions can be lessened by keeping patient dry, scopalamine patch, levsin (anti-cholenergics) • Use opioids/benzodiazepams as needed • Suctioning difficult for patient and likely not to be able to get deep enough

  18. Gastrointestinal Sx: EOL • Anorexia 60-80% • Xerostomia 55-70% • Nausea 15-30% • Vomiting 15-25% • Constipation 50% • Diarrhea <10%

  19. Anorexia • Corticosteroids • Megestrol acetate • Dronabinol • Other causes – gastritis/PUD – PPIs, early satiety/reflux – Reglan, oral thrush – anti-fungals. • Realize patient usually VERY comfortable with this!

  20. Dry Mouth • Hyposalivation • Mouth care and gum/candy, popsicles • Artificial saliva • Oral swabs/wash cloth • Pilocarpine 5mg tid • Mucositis • Diphenhydramine, dexamethasone, lidocaine, and nystatin swish and swallow

  21. Nausea/vomiting Anxiety, fear, anticipatory, psychologic factors, increased intra-cranial pressure Dopaminergic (narcotic – induced and many others) Serotinergic (chemo induced) Histamine (labrynthitis, meds) Vagally mediated (ulcers, masses, irritations…) Reflux, gastritis, regurgitation, masses, ulcers, gastric outlet obstruction Small bowel obstruction, impaction Renal (pyelonephritis, stones), liver (hepatitis, cirrhosis), gall bladder, uterine…

  22. A Mechanistic Approach • Central – • Increased pressures (tumor, swelling, hydrocephalus) – steroids, RT, surgery • Anxiety, fear, anticipatory – benzodiazipines, psychotherapy • Chemo-trigger Receptor Zone (narcotics, other meds, many GI causes) • Anti-dopaminergics – prochlorperazine (compazine), haloperidol, droperidol, trimethobenzamide (Tigan), metoclopramide (Reglan), promethazine (phenergan) • Can be given PO, suppository, some IM/IV, some even in a paste form

  23. A Mechanistic Approach • Nausea Center (chemotherapy induced) – • Anti-serotinergics – ondansetron (Zofran), granisetron (Kytril), dolasetron, palonosetron • IV, PO, and expensive • Vestibular-ocular reflex (with vertigo) – • Anti-histamines – Benedryl, Antivert, Atarax • Anti-cholinergics - Scopolamine • Oro-pharyngeal vagal – lidocaine swish and swallow, treat the lesion

  24. A Mechanistic Approach • Gastro-esophageal – • Reflux/regurg – prokinetic agents like metoclopramide (reglan), H2 blockers/Proton pump inhibitors • Gastritis/ulcers – H2 blockers/PPIs • Delayed gastric emptying (narcotics, DM) – metoclopramide • Gastric outlet obstruction – NG suction, surgery

  25. A Mechanistic Approach • Intestinal • Obstruction – NG suction, surgery, NPO with Octreotide (Sandostatin) • Impaction – remember to check rectal exam – may need manual dis-impaction, enemas • Other organs – try to treat underlying cause if possible, may also respond to meds effecting CRZ

  26. Other agents for nausea • CAM – aromas (peppermint, ginger), herbs (ginger, cola), mind-focusing (meditation), acupuncture • Dronabinol (marijuana) • Combination suppositories/gels • BDR (Benadryl, Decadron, Reglan) • Can add ativan, Tigan, compazine and others

  27. Constipation • Defined: • hard, infrequent stools, needing to strain for 10 minutes • Uncomfortable feeling • Incidence- • US nutrition- Male 8% Fem. 21% • Hospice 80% • Hospice on narcotics 90% • Hospital 66%; Home 22%

  28. Physiology • Meal passes out of stomach into small intestine, with the addition of gastric, pancreatic, and biliary secretions • Transit time is 1-2 hrs thru the small intestine, where digestion and absorption takes place • Large bowel transit time is 1-3 days, where bulk of water is removed and stool is formed • Final BM – when rectal ampula fills, increase abdomenal pressure, relax anal sphincter and “the brown river flows”

  29. Medications opioids calcium-channel blockers anticholinergic Decreased motility Ileus Mechanical obstruction Diet (lo fiber, hi meat and starch) Metabolic abnormalities (hi Ca) Spinal cord compression Dehydration Autonomic dysfunction (DM) Malignancy Constipation – causes:

  30. Opioids do Two things: • Block Bowel (opioid receptors in mesenteric plexus and bowel wall) • Decrease propulsion • Increase sphincter tone • Increase bowel tone • Block pain/discomfort with packed bowel

  31. General measures establish what is “normal” regular toileting gastrocolic reflex Check impaction – 98% in rectal vault – hard packed in stool to large to evacuate Diet – hi fiber (greens, fruits, bran…), fluids, additive fibers (avoid with opioids at EOL) Specific measures stimulants osmotics detergents lubricants large volume enemas Managementof constipation

  32. Stimulant laxatives • Prune juice • Senna (Senokot) • Casanthranol (Pericolace) • Bisacodyl (Dulcolax) * Good preventatives with opioid use

  33. Osmotic laxatives • Lactulose or sorbitol • Milk of magnesia (other Mg salts) • Magnesium citrate • Polyethylene Glycol (Miralax) * Good add-ons if stimulants not enough with opioid induced constipation

  34. Detergent laxatives(stool softeners) • Sodium docusate • Calcium docusate • Phosphosoda enema prn

  35. Prokinetic agents • Metoclopramide • Cisapride

  36. Lubricant stimulants • Glycerin suppositories • Oils • mineral • peanut

  37. Large-volume enemas • Warm water • Soap suds

  38. Mr. L – 62 yo with Colon cancer Mr. L has end-stage metastatic colon cancer, diagnosed 6 months ago, with liver mets, ascites, carcinomatosis. He failed chemo, now in hospice for 2 wks. Over 2 days he has had persistent vomiting, unrelieved with compazine, steroids, ativan, with reglan making it worse. Over this time his abdomen has become very distended, he has crampy peri-umbilical pain, and he has not had a BM in 7 days. Lately, his vomit smells slightly fecal-like and is brown. He is miserable and wants to die now!

  39. Mr. L – exam, tests? PE – In distress - Abdomen distended and tense, tympanitic - Bowel sounds hyper - Abdomen diffusely tender - No stool in vault on rectal, hemoccult negative Tests – KUB and upright abd x-ray shows dilated loops of bowel and multiple air-fluid levels

  40. Obstruction • Vomiting 90+%, Pain 75% • Hyperparastalsis • Absent bowel sounds – complications, perforation • X-ray - dilated loops, air-fluid levels on upright • Contrast only if surgical candidate • Consider Surgery

  41. Conservative Management • Antiemetics • Haloperidol, phenothiazines • Scopalamine • Octreotide - somatostatin • Dexamethasone • Ativan

  42. …Conservative management • Anticholinergics • Analgesics: • Opioids, SQ/IV • Consider NG suction (though very uncomfortable) • Keep PO intake limited (what goes in must come up!)

  43. Hospice emergencies • Acute arterial bleed – either GI or pulmonary source (though also could be peripheral artery/aorta) • From above – throwing up bright red blood, from below – bright red blood per rectum, from abd aorta – get acute rapid distention of abdomen (left side first), then cold pulseless feet • Usually the end catastrophic event but LOTS of anxiety, hard for family to watch, may have acute pain, then passes out • Morphine/ativan right away • Red towels to hide the blood • May need emergent hospitalization for family sake

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