Palliative Management Of:

1. Palliative Management Of: • Nausea And Vomiting • Dyspnea • Secretions • Delirium Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor, University of Manitoba Faculty of Medicine

2. MECHANISM OF NAUSEA AND VOMITING • vomiting centre in reticular formation of medulla • activated by stimuli from: • Chemoreceptor Trigger Zone (CTZ) • area postrema, floor of the fourth ventricle • outside blood-brain barrier (fenestrated venules) • Upper GI tract & pharynx • Vestibular apparatus • Higher cortical centres

3. Cortex CTZ GI VOMITING CENTRE Vestibular

4. Stimuli Of Vomiting Pathways

5. PRINCIPLES OF TREATING NAUSEA & VOMITING • Treat the cause, if possible and appropriate • Environmental measures • Antiemetic use: • anticipate need if possible • use adequate, regular doses • aim at presumed receptor involved • combinations if necessary • anticipate need for alternate routes

6. D D D 5HT 5HT 5HT 5HT 2 2 2 M M M VOMITING CENTRE H1 H1 CB1 H1 Effector Organs H1 CB1 Muscarinic Cannabinoid Dopamine Serotonin Histamine

7. From: Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice Arch. Dis. Child.2004;89;877-880 E S Antonarakis and R D W Hain

8. DyspneaInPalliative Care

9. DYSPNEA: An uncomfortable awareness of breathing

10. 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

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

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

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

14. 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

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

16. Opioids in Dyspnea • Uncertain mechanism • Comfort achieved before resp compromise; rate often unchanged • Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for 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

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

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

19. 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

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

21. Palliative Management of Secretions

22. Secretions - Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum SurveyGoldman A et al; Pediatrics 2006; 117; 1179-1186

23. Suctioning Increased Secretions Mucosal Trauma Managing Secretions in Palliative Patients • Factors influencing approach management: • Oral secretions vs.. lower respiratory • Level of alertness and expectations thereof • Proximity of expected death • “Death Rattle” – up to 50% in final hours of life • At times the issue is more one of creating an environment less upsetting to visiting family/friends • Suctioning: “If you can see it, you can suction it”

24. CONGESTION IN THE FINAL HOURS “Death Rattle” • Positioning • ANTISECRETORY: Scopolamine, glycopyrrolate • Consider suctioning if secretions are: • distressing, proximal, accessible • not responding to antisecretory agents

25. Atropine Eye DropsFor Palliative Management Of Secretions • Atropine 1% ophthalmic preparation • Local oral effect for excessive salivation/drooling • Dose is usually 1 – 2 drops SL or buccal q6h prn • There may be systemic absorption… watch for tachycardia, flushing

26. Delirium in Palliative Care

27. Definition Etiologically non-specific global cerebral dysfunction associated with changes in LOC, attention, thinking, perception, memory, psychomotor behavior, emotion and the sleep/wake cycle

28. DSM-IV Criteria • Change in consciousness with reduced ability to focus, sustain or shift attention • Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia • Abrupt onset (hours to days) with fluctuation • Evidence of medical condition judged to be etiologically related to disturbance

29. Characteristics • Abrupt onset • Disorientation, fluctuation of symptoms • Hypoactive vs.. hyperactive (restlessness, agitation, aggression) vs. mixed • Changes in sleeping patterns • Incoherent, rambling speech • Fluctuating emotions • Activity that is disorganized and without purpose

30. Delirium Types • Hypoactive • confusion, somnolence,  alertness • Hyperactive • agitation, hallucinations, aggression • Mixed (>60%) • features of both

31. Prevalence of Delirium • 20% - 44% on admission to a palliative care unit (common reason for admission) • 28% - 45% of patients developed delirium while on the palliative care unit • 68% - 90% prior to death • Lawlor et al (J Pall Care 1998) • n = 103 pts • 50% of episodes reversible • Terminal delirium in 88% • Hyperactive (5%) vs. hypoactive (47%) • Mixed (48%) most common

32. Delirium versus Dementia DeliriumDementia Abrupt onset Insidious onset Decreased/Fluctuating LOC LOC intact, alert Erratic behaviour Consistent behaviour Sleep/wake cycle change Minimal changes Reversible (theoretically) Irreversible

33. Causes Of Delirium In Palliative Care • Tumour • Primary, metastatic, leptomeningeal, paraneoplastic syndrome • Metabolic / physiologic • hypercalcemia • Hyponatremia (hypernatremia less commonly) • ↑ or ↓ glucose • anemia, hypoxia • CO2 • Renal or liver failure • Infection – UTI, pneumonia, biliary tract, wounds • Medication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretory • Medication / Drug withdrawal • Etc…..

34. Management Of Delirium In Palliative Care • Environmental • Quite, private setting: single room if possible • Low lighting, calendar, clock, familiar objects • Minimal room changes with unnecessary distractions • Fix the Fixable – if possible and appropriate • Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible • Effective sedation – with frank discussion of anticipated course • If delirium irreversible, goal of care is sedation • Sedation does not hasten the dying process • Will facilitate meaningful visiting • Encourage communication, even though patient not interactive