Transcript Wholihan, 2010 E L N E C Geriatric Curriculum

E L N E C
Geriatric Curriculum
End-of-Life Nursing Education Consortium
Session3:
Nonpain Symptoms at the
End of Life
Fairfield University
Quinnipiac University
School of Nursing ELDER Project
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Objectives:
1. Identify common symptoms associated
with end of life.
2. Discuss the need for continual
assessment.
3. Describe the role of various members of
the palliative care team to assess and
manage symptoms
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Symptom Management Requires• Ongoing assessment and evaluation
• Requires interdisciplinary
teamwork
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Common EOL Symptoms
• Respiratory
– Dyspnea
– Cough
• GI
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• General/Systemic
– Fatigue
– Weakness
• Psychological
Anorexia
Constipation
Diarrhea
Nausea
Vomiting
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Depression
Anxiety
Delirium
Agitation
Confusion
Case Study #6
Mr. C: Dyspnea/Fatigue
• Mr. C. is a 75-year-old African American man with end-stage cardiac
disease and long standing congestive heart failure including pulmonary
edema. He experienced his first myocardial infarction at 45 years of
age, had a quadruple bypass procedure at 58, and repair of an
abdominal aortic aneurysm at 62. He has been retired for 15 years
after working as an engineer. He lives at home with his wife, who is a
cancer survivor.
• He has led a very active life, even after retirement, but in the past few
months has experienced severe fatigue that leaves him unable to
participate in or enjoy previous activities. He often says, “I feel as if I
have no ambition,” and “I can’t do anything anymore. I am
worthless.” In the past few weeks, Mr. C. has been experiencing
shortness of breath, initially relieved with oxygen. Unfortunately, the
dyspnea has progressed during the past week and he has developed a
dry cough. He has no advance directive.
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Dyspnea
• Distressing shortness of breath
• Difficulty breathing
• Associated with anxiety, depression,
and decreased quality of life
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Assessment of Dyspnea
• Clinical assessment- it is what the
patient says it is.
Derby et al., 2010; Dudgeon, 2010
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Treatment of Dyspnea
• Oxygen therapy
• Pharmacologic treatments
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opioids
bronchodilators
diuretics
corticosteroids
Clemens & Klaschik, 2007; Derby et al., 2010;
Dudgeon, 2010; Jacobs, 2003
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Treatment of Dyspnea
• Non-pharmacologic
– Be calm and provide reassurance
– Counseling
– Pursed lip breathing
– Energy conservation
– Fans, elevation, positioning
– Distraction, relaxation exercise
Dudgeon, 2010
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Question?
• What have you done to provide nonpharmacologic treatment of dyspnea?
• How do you think Mr. C. would assess his
QOL?
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Fatigue
• Subjective
• Commonly associated
with many diseases
• Impacts all dimensions
of QOL
How is fatigue affecting Mr. C’s QOL?
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Causes of Fatigue
• Psychological
Stress
Anxiety
Depression
Family
• Disease and Treatment related
• Why is Mr. C. so fatigued?
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Treatment of Fatigue
• Non-drug strategies:
 Frequent rest periods
 Energy conservation
 Prioritize goals
 PT/OT
 Maintain nutrition & hydration
• Medical therapies:
 Blood transfusions
 Corticosteroids
 Antidepressants
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Anorexia and Cachexia
• Anorexia - loss of appetite, usually
with decreased intake
• Cachexia - lack of nutrition and
wasting
• Anorexia and cachexia often follow fatigue!
Wholihan, 2010
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A client in advanced stages of AIDS is reporting
fatigue. Which of the following assessment findings
is commonly associated with the symptom of fatigue?
a. anorexia /cachexia
b. reduced serum calcium
c. hyperthyroidism
d. increased hemoglobin/hematocrit
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Causes of Anorexia and
Cachexia
• Disease related
• Psychological
• Treatment related
• What cultural consideration might need to be addressed
with Mr. C.?
Wholihan, 2010
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Assessment of Anorexia and
Cachexia
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Physical findings
Impact on function and QOL
Calorie counts/daily weights
Lab tests
Skin breakdown
Wholihan, 2010
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Treatment of Anorexia and
Cachexia
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Treat the cause
Dietary consultation
Appetite stimulants
Parenteral / enteral
nutrition
• What long term planning needs
to be addressed with Mr. C.?
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Case Study #7
“Mr. T.” Diarrhea/Constipation
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• Mr. T. is an 85-year-old Korean widower who has been in a nursing
home for two years with progressive dementia. He is unable to
communicate with his two adult sons, their wives, his grandchildren, or
with the staff. In fact, the family visits infrequently and is obviously
distressed when they observe Mr. T. He has been unable to ambulate,
requiring full assistance with transferring to or from a chair.
• He had several episodes of aspiration one year ago, when a feeding
tube was placed. He had significant diarrhea when tube feedings were
first started. However, in the past few months, he has been
constipated, requiring disimpaction several times each month. During
the past week, he has had frequent episodes of liquid diarrhea.
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Constipation
• Infrequent passage
of stool
• Stool that is hard &
difficult to pass
• Frequent symptom
in palliative care
• Prevention is key
Economou, 2010; Sykes, 2004
• What family teaching is essential?
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Causes of Constipation
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Decreased fluid and food intake
Decreased physical activity
Medications
Chronic illness
• What cultural considerations need
to be addressed for Mr. T.?
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Assessment of Constipation
• Bowel history
• Physical symptoms
Rubbing abdomen
Restlessness
Change in behavior
Crying; resisting care
• Abdominal assessment
• Rectal assessment
• Medication review
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Economou, 2010
Treatment of Constipation
• Medications
 Senokot
 Peri-Colace
 Dulcolax
 Others
• Dietary/fluids
• Comfort measures, privacy
• Key-anticipate & prevent
• What long term planning should be
considered for Mr. T.?
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Berger et al., 2007; Economou, 2010
A client with terminal cancer has been prescribed
fentanyl and dilaudid for pain. Which of the
following goals would be essential to include in the
client's plan of care?
a. Client will remain continent of urine and
stool.
b. Client will have usual bowel pattern.
c. Client will not report dyspnea.
d. Client will not report fatigue.
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Which of the following clients is at the highest
risk for developing constipation?
a. A 48-year-old with metastatic cancer of the spine on
high doses of opioids who has dehydration.
b. A 76-year-old with cancer of the bowel who has
begun treatment for Clostridium difficile.
c. An 85-year old with hepatic encephalopathy who is
receiving prescribed neomycin (Mycifradin) and
lactulose.
d. A 90-year-old with uterine cancer and laboratory
evidence of hypocalcemia and hyperkalemia.
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The home health worker is caring for a client at the end of life
who has a recent history of constipation. Which of the
following may mean that there is fecal impaction?
a.
b.
c.
d.
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foul smelling diarrhea
sudden onset of liquid stool
fatty looking stools
blood and mucous strands in stool
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Case Study #2 "Mr. Hayes“ Nausea/depression
• Mr. Hayes is a 73-year-old with metastatic colon cancer, which has
spread throughout his abdomen. He has been a resident in your NH
for about 6 months and recently developed intractable nausea and is
experiencing rapid weight loss. He is barely capable of managing any
activities of self care. He is very embarrassed and distressed by this.
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Mr. Hayes has been found to have a non-resectable partial small
bowel obstruction. He asks, "How much longer do I have?" and "Can
we speed this up?" “I don’t want my daughter to see me suffer.” “I
don’t want to be in pain.” The patient admits to feeling down but
denies any suicidal ideation. He is clearly concerned about becoming a
burden to his family. He is a devout Catholic and mentions to the NA
that he is certain his symptoms and suffering are a punishment for his
having a divorce ten years ago.
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Depression
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Ranges from sadness to suicidal
Often unrecognized and undertreated
Occurs in 25-77% of terminally ill
Estimated to occur in 22% of nursing
home residents
AGS, 2002; Coyle, 2010; Dahlin, 2009
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Causes of Depression
• Physical: pain, illnesses,
medications, sensory
deficits
• Psychological: loss, grief,
memory problems
• Social: isolation, conflicted
relationships
• Biological: family history,
genetics
• Medications
– Why is Mr. Hayes depressed?
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Depression
• Depression is the most frequently observed symptom
in the terminally ill
– Observed in 77% of persons with far-advanced cancer
• Suggested questions to assess depression:
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“Can you describe your mood for me?”
“How long have you felt this way?”
“What is the feeling of depression like for you?”
“Have you noticed changes in your level of interest in
normal activities?”
– “How would you rate your feeling of depression on a 1-to-10 scale?”
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©2001 D.J. Wilkie & TNEEL Investigators
N E C Geriatric Curriculum
(Isaacs, 1998)
MOOD SCALE
(short form)
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES /
NO
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Although differing sensitivities and specificities have
been obtained across studies, for clinical purposes a score > 5 points is suggestive of depression
and should warrent a follow-up interview. Scores > 10 are almost always depression.
http://www.stanford.edu/~yesavage/GDS.english.short.score.html
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PHQ-9
• Scoring: add up all checked boxes on PHQ-9
– For every 􀀳 Not at all = 0; Several days = 1;
– More than half the days = 2; Nearly every day = 3
• Interpretation of Total Score - Total Score Depression Severity
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1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression
PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a
trademark of Pfizer Inc.
A2662B 10-04-2005
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Pharmacological Interventions
for Depression
• Antidepressants
• Stimulants
• Nonbenzodiazepines
• Steroids
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Do you think Mr. Hayes would benefit from medication?
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Nondrug Interventions for
Depression
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Empathetic listening
Assurance and support
Concrete information
Symptom management
Relaxation/imagery
Counseling
• What nondrug therapy might work best for Mr. Hayes?
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Mr. Hayes
• When would be a good time to talk to Mr.
Hayes about palliative care and an
advance directive?
• Is an additional suicide assessment
indicated?
• How might various members of the team
contribute to Mr. Hayes’ care?
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Suicide Assessment
• Do you think life isn’t worth living?
• Have you thought about how you
would kill yourself?
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Key Palliative Care Team Roles
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Patient advocacy
Assessment, Assessment, Assessment
Pharmacologic treatments
Non-pharmacologic treatments
Patient/family teaching
Presence
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Conclusion
• Multiple symptoms are common
• Coordination of care with physicians
and other team members
• Use drug and nondrug treatment
• Patient/family teaching and support
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Last question…
• What one practice improvement can
you begin as a result of attending this
session?
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References
City of Hope & the American Association of
Colleges of Nursing, 2007; Revised, 2010. The
End-of-Life Nursing Education Consortium
(ELNEC)- Geriatric Training Program and
Curriculum is a project of the City of Hope (Betty
R. Ferrell, PhD, FAAN, Principal Investigator) in
collaboration with the American Association of
Colleges of Nursing (Pam Malloy, RN, MN, OCN,
Co-Investigator).
Supported by DHHS/HRSA/BHPR/Division of Nursing
Grant # D62HP06858
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