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END-OF-LIFE CARE: Module 5

END-OF-LIFE CARE: Module 5. Non-Pain Symptom Management. Case.

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END-OF-LIFE CARE: Module 5

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  1. END-OF-LIFE CARE:Module 5 • Non-Pain Symptom Management Module #5

  2. Case • Imagine you have advanced pancreatic cancer. You’ve lost 30 pounds over the past few months. There is no evidence of GI obstruction and you are not nauseated. You are very weak, and are now bedridden, with no appetite. Your mouth is dry. Your spouse keeps trying to get you to eat and you try, but you just can’t do it. You keep wondering why this is happening, and your spouse is very upset. You are admitted to the hospital and lab tests reveal that you are dehydrated. The intern comes to insert an IV. Module #5

  3. Learning Objectives • Increase understanding of how physical and mental factors affect symptomatology • Be able to use this understanding in the treatment of patients suffering from nausea and vomiting, dyspnea, and cachexia/anorexia/asthenia • Incorporate this content into your clinical teaching Module #5

  4. Outline of Module • Non-pain symptoms at EOL • Symptom analysis checklist • Nausea and vomiting • Break • Dyspnea • ‘Terminal Syndrome Characterized by Retained Secretions’ • Cachexia/anorexia/asthenia Module #5

  5. Symptoms as Clues • A physical or mental phenomenon, circumstance or change of condition arising from and accompanying a disorder and constituting evidence for it… specifically a subjective indicator perceptible to the patient and as opposed to an objective one (compare with sign). The New Shorter Oxford English Dictionary Module #5

  6. Disease as a Clue to the Symptom • Questions to ask: • How does the disease give rise to the symptom? • What cognitive, affective, and spiritual components are involved? Module #5

  7. From the Patient’s Perspective • A symptom is what is bothersome Module #5

  8. Physiological Factors Local Central Mental Factors Cognitive Affective Spiritual Symptom Analysis Checklist Module #5

  9. Physiological factors Local: Central: Mental Factors Cognitive: Affective: Spiritual: Skills Practice: Patient with pain symptoms due to metastatic bone cancer Module #5

  10. Non-Pain Symptoms at the EOL • Akathesia Anhedonia Anorexia Anxiety Colic Confusion Constipation Cough Crying Death rattle/secretions Diarrhea Dizziness Drooling Dry skin Dysarthria Dysgeusia Dyspepsia Dysphagia Dysphoria Dyspnea Dysuria Failure to thrive Fatigue Fear Fecal incontinence Fever Flatulence Halitosis Hallucinations Hearing loss Hiccups Impotence Irritability Memory loss Mucositis Muscle spasms Nausea Odor Panic attacks Peripheral edema Photosensitivity Polydipsia Polyuria Pruritus Restlessness Sexual dysfunction Sleep disorders Stomatitis Taste alterations Urinary frequency Urinary incontinence Visual problems Vomiting Xerostomia • Index, Oxford Textbook of Palliative Medicine, 1998 Module #5

  11. Nausea & Vomiting • When you were a resident (or if you are a resident now: when you were in medical school), what were you taught about antiemetics? Module #5

  12. Nausea & Vomiting As Protective Mechanisms • Serial barriers: • 1. Sight, smell, taste • 2. Chemoreceptors and mechanoreceptors • 3. Brain receptors • 4. Message to vomit residual gut contents Module #5

  13. A Central Final Pathway for Nausea (Dopamine, Serotonin) (???) CNS CTZ VOMIT CENTER (Acetylcholine, Histamine) Vestibular Apparatus GI Tract (Acetylcholine, Histamine) (Acetylcholine, Histamine, Serotonin + mechanoreceptors) Module #5

  14. Receptor Affinity Common Antiemetics Drug Receptors Dopamine Musc. Chol. Histamine Scopalomine >10,000 .08 >10,000 Promethazine 240 21 2.9 Prochlorperazine 15 2100 100 Chlorpromazine 25 130 28 Metoclopramide 270 >10,000 1,000 Haloperidol 4.2 >10,000 1,600 Potency: K1 (nanomolar) The lower the number, the stronger this agent is at blocking this receptor Adapted from Peroutka and Snyder, 1982 Module #5

  15. Causes of Nausea & Vomiting • Vestibular • Obstruction • Mind • Dysmotility • Infection (irritation) • Toxins (taste and other senses) Module #5

  16. Vestibular Apparatus • Nausea with head movement • Medicated by acetylcholine and histamine receptors • Most anticholinergic, antihistamine drugs will help Module #5

  17. Obstruction/Opioids • Constipation = most common cause • External or internal obstruction • Mediated by mechanoreceptors and/or chemoreceptors • Controversy as to best medication for true bowel obstruction • Anti-constipation meds for constipation Module #5

  18. Mind • Memory, meaning, and emotions can be very powerful • Manipulate taste and other senses Module #5

  19. Dysmotility • Multiple causes • Upper intestinal dysmotility is very common • Prokinetics: • Metoclopramide (upper only) • Senna (lower only) Module #5

  20. Infection/Irritation • Mediated through chemoreceptors • Gut and adjacent organ inflammation can trigger • Anticholinergic/antihistaminic medications can help Module #5

  21. Toxins • Most important source: medications • Various mechanisms of inducing nausea • Treatment depends on mechanism of action Module #5

  22. Opioid-Related Nausea • Incidence of dysmotility caused by opioids may be underestimated • Haloperidol recommended for nausea related to chemoreceptor trigger zone (CTZ) Module #5

  23. 5HT3 Antagonists • May have a variety of uses • Minimally tested outside of their use in chemotherapy-related nausea • Expensive Module #5

  24. Symptom Analysis Checklist • Physiological Factors • Local • Central • Mental • Cognitive • Affective • Spiritual Module #5

  25. Exercise 1: The Runner • Are you dyspneic? Short of breath? • What is your O2 saturation level? • What is happening locally in you chest? • What do you think about your run? • Any spiritual importance? • Are you suffering? Module #5

  26. Exercise 2: Being Held Under Water • Are you dyspneic? Short of breath? • What is your O2 saturation level? • What is happening locally in you chest? • What do you think about your run? • Any spiritual importance? • Are you suffering? Module #5

  27. Exercise 3: Lung Cancer • Imagine that you have lung cancer, on top of pre-existing COPD • You are getting winded with the least possible exercise. • Coming back from the bathroom to the bed you are now very dyspneic • You wish there was a window you could open • The nurse measures your O2 Sat • There is a low-pitched beeping sound, which you know is not good • The nurse looks distressed and rushes from the room Module #5

  28. Treating Dyspnea • Physiological Factors • Local: Fan, cool breeze • Central: WOB may be particularly responsive to low dose opioids • Mental factors • Cognitive: Education, reframing • Affective: Emotional support, benzodiazepines for panic sensation Module #5

  29. Dyspnea in the Dying • Common • - 70% of patients in last 6 weeks of life • Reuben & Mor, 1986 • Care has traditionally focused more on lung physiology than central processes • Not always correlated with oxygen level Module #5

  30. ‘Terminal Syndrome Characterized by Retained Secretions’ • Relative lack of cough • Not always associated with dyspnea • Deep suctioning ineffective • Hydration may flood lungs • Because patient is unable to cough • Use of antibiotics, IV fluids controversial Module #5

  31. Treatment of this Terminal Syndrome • Peaceful environment • For dyspnea • Opioid-naïve: 2-4 mg SC morphine or equivalent q1-2 hours • On opioid: increase dose by 25% • Lorazepam or chlorpromazine for agitation • For secretions • Oxygen, fan Module #5

  32. Case Exercise • Imagine you have advanced pancreatic cancer. You’ve lost 30 pounds over the past few months. There is no evidence of GI obstruction and you are not nauseated. You are very weak, and are now bedridden, with no appetite. Your mouth is dry. Your spouse keeps trying to get you to eat and you try, but you just can’t do it. You keep wondering why this is happening, and your spouse is very upset. You are admitted to the hospital and lab tests reveal that you are dehydrated. The intern comes to insert an IV. Module #5

  33. Definitions • Cachexia = physical wasting • Anorexia = lack of appetite • Asthenia = weakness, fatigue Module #5

  34. Physiological Mechanisms • Complex physiology • Best studied in cancer • Key finding: Not the same as starvation • Significant physiological differences • Often not reversed by artificial feeding Module #5

  35. Cachexia/Anorexia/Asthenia • Strongly correlated with decreased functional status • Associated with multiple losses • - Appetite and pleasure in eating • - Energy level • - Independence • - Activities of daily living Module #5

  36. Medical Interventions • Treat underlying nausea, pain, depression • Artificial feeding may or may not be appropriate • To increase appetite • Megestrol acetate • Steroids • Cannabinoids • Transfusion for anemia • May or may not improve asthenia Module #5

  37. Psychological Interventions • Treat underlying depression • Address loss in patient and family • Reflect back losses of nurturing, functional status and independence • Help patient/family redefine these losses • Coach in new ways to nurture • Consider therapies to compensate for functional loss Module #5

  38. Artificial Hydration at the End of Life is Controversial Module #5

  39. Brainstorm • What are some arguments on both sides of the EOL artificial hydration controversy? Module #5

  40. In Favor: Minimum standard of care ? Greater comfort ? Less confusion, restlessness Against: Not clear that it prolongs life Increases urine output, GI secretions/nausea, & pulmonary secretions with pneumonia Not clear that it alleviates thirst Decreasing fluids acts as natural anesthesia Some Arguments... Module #5

  41. Medical Issues Aside… • Some prefer a more ‘natural death’ without artificial hydration • Others may see hydration as minimal, humane (if technical) support • Important to take patient goals and situation into account Module #5

  42. Learning Objectives • Increase understanding of how physical and mental factors affect symptomatology • Be able to use this understanding in the treatment of patients suffering from nausea and vomiting, dyspnea, and cachexia/anorexia/asthenia • Incorporate this content into your clinical teaching Module #5

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