به نام خداوند یکتا

1. به نام خداوند یکتا درمان مراقبتی جسمی در بیماران مبتلا به سرطان پیشرفته دکتر راضیه قربانی پزشک عمومی همکار تیم طب تسکینی

2. منابع • GUIDELINES & PROTOCOLS ADVISORY COMMITTEE 2011

3. تنگی نفسDyspnea

4. تعریف: اشکال و ناراحتی هنگام تنفس که شدت متغیر دارد و می تواند همراه با هیپوکسمی ، تاکی پنه یا ارتوپنه باشد یا نباشد. در 80 درصد بیماران با سرطان پیشرفته اتفاق می افتد.

5. ارزیابی تنگی نفس • از بیمار بخواهید که شدت تنگی نفس خود را تعیین کند (نمره 1 تا 10) • علل زمینه ای را مشخص کنید و در صورت نیاز درمان نمایید. (مثل آنمی ، آریتمی ، آمبولی ریه، اضطراب ...) • در دو سوم موارد شرح حال و معاینه فیزیکی منجر به تشخیص درست می شود. • آزمایشات : CBC/diff, electrolytes, creatinine, oximetry +/- ABGs and pulmonary function, ECG • تصویر برداری : Chest X-ray and CT scan

6. استراتژی های درمانی • اثر اپیویید ها برای درمان علامتی تنگی نفس اثبات شده است. • دوز درمانی استفاده شده در درمان تنگی نفس (morphine 2.5-5 mg PO (SC dose is half the PO dose) q4h) ریت تنفسی و میزان اکسیژن خون را کاهش نمی دهد. • اکسیژن برای رفع هیپوکسمی مفید است. • کنترل موفق تنگی نفس رنج بیمار را کاهش می دهد و کیفیت زندگی او را ارتقا می دهد. • درمانهای غیر دارویی شامل آموزش و اقدامات حمایتی همیشه مهم هستند. • درمانهای دارویی : Opioids, +/- benzodiazepines or neuroleptics, +/- steroids

7. درمانهای غیر دارویی و اقدامات حمایتی • جریان هوا (fan) / هوای مطبوع • حالت خوابیدن بیمار • کم کردن لباس ها و استفاده از لباس گشاد • آرام سازی (Relaxation) • کنترل تنفس • ذخیره انرژی

8. What can be done? • Sitin a chair or recliner • Elevate your head on pillows when lying in bed • Sit with your hands on your knees or on the side of the bed leaning over the bedside table • Practice pursed lip breathing technique. Take slow, deep breaths, breathing in (inhale) through nose and then breathe out (exhale) slowly and gently through pursed lips (lips that are “puckered” as if you were going to whistle) • Increase air movement by opening a window, using a fan or air conditioner. Apply a cool cloth to your head or neck • Use oxygen as directed by your healthcare provider • Take medication as directed by your doctor • Keep your environment quiet to decrease feelings of anxiety • Use relaxing activities such as prayer, medication, calming music, and massage • Notify the team if your shortness of breath is not relieved or gets

9. اقدام آخر در موارد تنگی نفس که به درمان های دارویی وغیر دارویی پاسخ نمی دهند : مشاوره با متخصص طب تسکینی Palliative Sedation

10. یبوستConstipation

11. ارزیابی یبوست • عادات اجابت مزاج بیمار قبل از بیماری و در حال حاضر چگونه است. • هدف راحتی دفع و تعداد دفعات دفع مناسب است. • تا زمانی که ناراحتی برای بیمار وجود نداشته باشد کاهش دفعات دفع در بیمارانی که دریافت غذا و فعالیت کمتری دارند قابل قبول است.

12. Constipation Management Strategies • علل مختلفی وجود دارد مثل کاهش دریافت غذا ، مایعات و حرکت و عوارض داروها • از مداخلاتی مثل انما و شیاف بپرهیزید. این مداخلات در بیماران نوتروپنیک یا ترومبوسیتوپنیک یا هنگامی که بیماری رکتال وجود دارد کنتراندیکه هستند. • Fecal Impaction با انجام معاینه و عکس ساده شکم بررسی می شود. • زمانی که ریسک فاکتورها وجود دارند از ملین ها به صورت مداوم استفاده کنید. اثر ملین ها زمانی که بر طبق پاسخ افزایش دوز داشته باشند بیشترین مقدار است (Bowel Protocol) • برای پیشگیری و درمان داروی Sennosides خط اول درمان است. • لاکتولوز که یک ملین اسموتیک است مزه ناخوشایندی دارد و نفخ ایجاد می کند. • برای بیماران با یبوست ناشی از اپیویید ، بعد از خط اول درمان و ملین های اسموتیک ، متیل نالتروکسان کمک کننده است.

14. What can be done? • Record when the bowel movements have occurred. • Follow a regular bowel regimen, even if you are not constipated (many medications can cause constipation) • Drink as much fluid (liquids) as is comfortable. Drinking warm liquids may promote bowel movement • Eat more fruits and fruit juices, including prunes and prune juice • Increase physical activity if possible. Walking can be beneficial • Take laxatives/stool softeners as ordered by healthcare provider • Sit upright on toilet, commode or bedpan • Establish routine times for toileting • Avoid bulk laxatives if not taking enough fluids • Notify hospice/palliative care team if constipation continues

15. دلیریوم

16. What is delirium? • A sudden change in a person’s metal status over a period of hours to days • Mental clouding with less awareness of one’s environment • Confusion about time, place and person

17. What are the signs and symptoms of delirium? • Reversal of sleep and awake cycles • “Sundowning” or confusion that is worse at night • Mood swings that may change over the course of a day • Difficulty focusing attention or shifting attention • Hallucinationsor seeing, hearing or feeling things which are not there • Agitation and irritability • Drowsiness and sluggishness • May be restless and anxious

18. What can be done for delirium? • Delirium is common at the end-of-life. • Keep the patient safe • Remind the patient who you are when you assist with caregiving. Tell them what you are going to do. For example, “I am going to help you get out of bed now” • Offering support such as “I am right here with you” • Try to maintain a routine and structure • Avoid asking a lot of questions • Provide a quiet, peaceful setting, without TV and loud noises • Play the patient’s favorite music • Keep a nightlight on at night • If starting a new medication, watch for improvement, worsening or side effects and report to healthcare provider

19. Pharmacological Treatmentsin hypoactive patients • AVOID sedatives • Haloperidol: minimum effective dose to control hallucinations

20. Pharmacological Treatmentsin Hyperactive (agitated) patient • Antipsychotic Start with least sedating most sedating until agitation controlled • haloperidol • risperidone • loxapine • olanzapine • quetiapine • methotrimeprazine • AVOID benzodiazepines • Reassess frequently

21. خستگی و ضعف • Although most cancer patients report thatfatigue is a major obstacle to maintaining normal dailyactivities and quality of life, it is seldom assessed andtreated in clinical practice. • Fatigue is a highly prevalent condition among cancerpatients.

22. What is fatigue? • Tiredness, exhaustion, or lack of energy not relieved by rest • A condition which impacts your ability to perform your usual or expected activities • Seen frequently in hospice and palliative care patients • A complicated symptom which can have many causes including disease, emotional state, and treatments • Sometimes comes with depressed feelings

23. What are the signs of fatigue? • “Just too tired” to perform your normal activities or routines • Lack of appetite or not having energy to eat • Sleepiness • Not talking • Depression

24. Cancer-related fatigue can be an expression of (pre-existing) depression and canalso be a cause of depression. The two-question test consists of the following questions: • “In the last month, have you often felt dejected, sad, depressed, or hopeless?” • “In the last month, have you gotten much less pleasure than usual out of thethings that you normally like to do?”

25. Fatigue Assessment • درمان علل برگشت پذیر خستگی • Anemia • Dehydration • Hypokalemia • Hyponatremia • Hypomagnesemia • Hypo/Hypercalcemia • Hypothyroidism • Medication induced • Alcohol/drug abuse • Infection • Sleep disorder • Obstructive Sleep Apnea • Chronic Fatigue Syndrome

26. Non-pharmacological Treatments • Gradually increase your activity. Do so gradually in order to conserve energy • Keep a log of which time of day seems to be your best time • Plan, schedule and prioritize activities at optimal times of the day • Eliminate or postpone activities that are not your priority • Change your position and do not just stay in bed • Use sunlight or a light source to cue the body to feel energized • Try activities that restore your energy, such as music, or spending time outdoors in nature or meditation • Allow caregivers to assist you with daily activities such as eating, moving or bathing if necessary. Plan activities ahead of time • Encourage your family to be accepting of your new energy pace

27. Rest and sleep better • Listen to your body – rest as needed • Establish and continue a regular bedtime and awakening • Avoid interrupted sleep time and try to get continuous hours of sleep • Plan rest times or naps during the day late morning and mid afternoon • Avoid sleeping later in the afternoon which could interrupt your night time sleep • Ask if using oxygen when you sleep will help you to sleep better

28. Increase food intake • Try nutritious, high protein food • Small frequent meals • Add protein supplements to foods or drinks • Frequent mouth care (before and after meals) • Ask about possible use of medications to stimulate your appetite or relieve fatigue

29. Contraindications to exercise inpatients with cancer • Absolute contraindications – acute illnesses – acute worsening or decompensation of chronicillness – fever above 38°C – pain – inadequately controlled arterial hypertension • Relative contraindications – anemia (hemoglobin below 8 g/dL) – thrombocytopenia, coagulopathy – bone metastases – accompanying illnesses such as coronary heartdisease, occlusive peripheral arterial disease, arterialhypertension, diabetes mellitus, arthrosis – administration of cytostatic agents on the same day – mediastinal/cardiac radiation therapy – flu-like symptoms under immunotherapy – epilepsy

30. درمان های دارویی • Hematopoietic growth factors • Psychostimulants : متیل فنیدیت • Corticosteroids • Thyreoliberin (TRH) • Phytotherapeuticagents (Ginseng) استفاده از آنتی دپرسانت ها در مطالعات بالینی بهبودی در علائم خستگی ناشی از سرطان نشان نداده است.

31. افسردگی • Depression occurs in 13-26% of patients with terminal illness • Patients are at high risk of suicide and have an increased desire for hastened death • A useful depression screening question is, “Have you been depressed most of the time for the past two weeks?” • A diagnosis of depression in the terminally ill may be made when at least two weeks of depressed mood is accompanied by symptoms of hopelessness, helplessness, worthlessness, guilt, lack of reactivity, or suicidal ideation

32. Risk factors • personal or family history of depression, • social isolation, • concurrent illnesses (e.g., COPD, CHF), • alcohol or substance abuse, • poorly controlled pain, • advanced stage of illness, certain cancers (head and neck, pancreas, primary or metastatic brain cancers), • chemotherapy agents (vincristine, vinblastine, asparagines, intrathecal methotrexate, interferon, interleukin), • corticosteroids (especially after withdrawal), • abrupt onset of menopause (e.g. withdrawal of hormone replacement therapy, use of tamoxifen).

33. Management Strategies • Non-pharmacological treatments are the mainstay of treatment for the symptom of depression without a diagnosis of primary affective disorder • Treatment of pain and other reversible physical symptoms should occur before initiating antidepressant medication.

34. Non-pharmacological Treatment for Depression • Exercise, rest, nutrition, social and spiritual support • Psychotherapy • Cognitive Behavioural Therapy

35. What can be done for depression? You may: • Optimize physical status with rest and nutrition • Set small, realistic, achievable goals • Utilize relaxation techniques • Consider complementary therapies such as aromatherapy, art and music therapy Your caregiver may: • Keep you and your area safe • Let you know that they will be there • Allow you to express feelings • Allow you to control as much as possible related to treatment decisions and activities

36. Edema (Swelling) • Puffiness or swelling of legs, ankles, feet, arms, face, or hands • Clothes, shoes, rings, or watches that feel too tight • Skin that is shiny, feels tight, indents or dimples when pressed • Sudden weight gain

37. What can you do for the patient to prevent and treat edema? • Elevate the affected area when sitting or lying down • Remind them to avoid crossing legs when sitting, and avoid standing for long periods • Teach correct application and care if compression stockings (support stockings) are worn • Encourage limiting their intake of salt and sodium

38. How you can support the family • Inform the family that they play an important role in managing the edema • Reinforce that sometimes edema may not go away • Reinforce that the goal is patient comfort and edema may not be painful • Teach them how to elevate affected area (For example: use of pillows, recliner, and/or propping feet on a stool) • Let the family know that if moving the affected area appears to cause pain, tell the interdisciplinary team

39. Seizures The person having a seizure may have some or none of these signs. • Muscle jerking/twitching (convulsion) • Stiffening of the body • Unable to awaken for a period of time • Loss of bladder control • Blurred vision, eyes rolling back, blank staring or blinking • Inability to speak, difficulty talking • Sudden confusion or memory loss • Recurring movements – chewing, lip smacking, clapping

40. What can you do for the patient? If you are with a patient who is having a seizure it is important to keep in mind that safety is the first concern

41. How can you support the family? • Remain with the patient throughout the seizure • Encourage the family to remain calm • Family members may believe the patient will “swallow” his/her tongue. This is not possible, though the tongue may “relax” in the pack of the throat causing the airway to be obstructed. If it is determined the patient is not breathing after a seizure, reposition his/her head to open the airway and administer breaths if necessary • Discourage the family from restraining the patient or placing anything in his/her mouth, which could cause injury to the patient or family member • Family members may have been instructed by a nurse or doctor to administrate certain anti-seizure or sedating drugs during the seizure • Contact the hospice or palliative care nurse if you have any questions or concerns

42. Self-Care for the Caregiver Physical needs • Remember to take care of your own health • Keep your own doctor appointments • Schedule time to eat. Have at least 3 healthy but simple meals a day • Learn to make meals in advance. Ask friends/family if they could help with making meals • Ask how best to provide care to your loved one and prevent injuring yourself • Take time to rest, especially if sleeping has become hard for your • Avoid/limit the use of tobacco and alcohol as they make it difficult to fall asleep • Try to get some form of exercise in the day • Take time alone. This can include walking, reading, listening to music, baths, praying, gardening, etc.

43. Communication needs • Tell people about your worries. These people may be family, friends, or some of the healthcare providers working with you to help care for your loved one • Be informed! Ask what signs and symptoms to expect from the patient so that you are prepared to deal with them • Get organized and set realistic goals for your day. Keep it real and be flexible. Set limits • Ask others to help with whatever you or your loved one needs

44. Emotional/spiritual needs • Keep relationships with family and friends to avoid feeling alone. If it is difficult for you to get out, ask people to come visit. Let people take care of you and allow your loved one to say thank you for all you do • Work with your team to provide time to get out of the home to enjoy social activities or attend support groups. When possible, keep doing favorite activities. Try to keep things simple • Talk about your fears about what is happening to your loved one. Also, talk about any concerns or frustrations you may have • Even though you are feeling stressed, tell yourself every day you are doing a great job • Let your hospice/palliative staff know if you are feeling overwhelmed. Your team has ways to help, including nursing assistants and other resources • Attend to your spiritual needs by calling or visiting your clergy, church or synagogue • Have your own “special space.” This can be your room, a chair, a table, etc. Someplace that is yours where you can go unwind • Seek additional professional help if you are feeling scared, helpless, lost, or depressed • Breathe and laugh