Transcript 3. Non Pain Symptoms Overview - 65.44 KB

Palliative Care:
Non pain symptoms
Elizabeth Whiteman, M.D.
Goals and Objectives
• Be able to review and recognize other non- pain
symptoms in palliative care
• Be able to assess and control non-pain
symptoms
• Assist in treatment coordinating with other
needed treatments
• Understand use of non pharmacologic
interventions
• Understand how to use pharmacologic
treatments and prevent new side effects
Non Pain Symptoms
 Multiple “other” symptoms that can cause
significant problems at end of life
 Importance of these symptoms has been found
in studies to be a significant burden on patients
 Management and control of symptoms is the
responsibility of the all the physicians and
nurses caring for their patients
 Symptoms can and should be addressed during
active treatment as well as with end of life
Non Pain Symptoms
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Dyspnea
Constipation
Nausea and Vomiting
Anorexia, weight loss and cachexia
Fatigue and weakness
Depression, Anxiety and insomnia
Delirium and agitation
Last Hours (days)
Case 1
• 80 year old patient with metastatic lung cancer
and COPD. He is living at home and complains
of severe shortness of breath with minimal
exertion. He still smokes 3 cigarettes a day and
has a chronic cough. He is aware of his
prognosis and is DNR. His O2 sat is 92% on
room air on O2 4L nasal cannula 24 hours a day
• What can we recommend to help his shortness
of breath?
• A. Set a smoking quit date and refer to a stop
smoking group
• B. Remind him of the importance of a strict low
salt diet
• C. Morphine Sulfate 2.5-5mg every 4 hours as
needed for shortness of breath
• D. Add diuretic for fluid overload
• E. Increase his oxygen to 5L
Answer C
• Opioids are safe and effective for the relief of
dyspnea
• They do not cause decrease in oxygen saturation
• When used appropriately patients report less
breathlessness and improved exercise tolerance
• Monitor for symptom control per patients
report, titrate up as per symptoms
Dyspnea
• Assess cause of symptom “short of breath”
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Cancer related
Cardiac or CHF
Infection
COPD or underlying lung disease
Anxiety
Spiritual suffering
Dyspnea
• Treatment
▫ Non pharmacologic
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Elevate head of bed
Breathing exercises
Relaxation techniques
Rest between exertion (energy conserve)
Electric fan for increased air flow
Room with ventilation and windows
Oxygen 2-4 L nasal cannula as needed
Dyspnea
• Pharmacologic
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Narcotics: Morphine, Oxycodone, Hydromorphone
Benzodiazepines to relieve breathlessness
Diuretics if fluid overload
Steroids for asthma or inflammation
Inhalers or nebulizer for bronchospasm
Drying agents if increased secretions
 Scopalamine patch , Glycopyrrolate, atropine drops
sublingual
• STOP the cause: excess IV fluids, G tube feeds
Case 2
 A 75 year old woman with metastatic breast cancer
is admitted with new abdominal pain and no bowel
movement for 10 days. She also has no appetite and
feels nausea. She is on long acting Morphine 30mg
bid which controls her pain from the cancer. Her
abdomen is distended and there is firm hard stool in
her rectum. She has bowel sounds and the x-ray
shows stool throughout the colon.
 What is the first thing you can do to help her
abdominal pain?
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A. Stop her Morphine
B. Keep her NPO and place an NG tube
C. Start Metoclopramide IV around the clock
D. Give her an enema and start an oral laxative
E. Call surgery to evaluate for possible
obstruction
Answer D
• Constipation likely due to opioids
• Patients on opioids need to be on preventative
treatment for constipation
• Full assessment of cause should be investigated
• Treatment of coexisting symptoms also needs to
be managed (BUT TREAT UNDERLYING
CAUSE)
• Avoid causing return of other symptoms and
keep pain treatment also in mind
Constipation
• Discomfort associated with reduced frequency of
bowel movements
• Causes can be multifactorial
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Medications
Dehydration
Less physical activity
Metabolic abnormalities
Decreased oral intake
Mechanical obstruction
Constipation
• Treatment
▫ Non Pharmacologic
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Increase oral intake and fluids
Increase mobility and activity if able
Increase fiber and fruit juices, prunes etc
Positional : commode, sitting upright
Privacy
• Pharmacologic
▫ Stool softeners
▫ Stimulant laxatives
 senna, dulcolax
▫ Osmotic laxatives
 Milk of magnesia, lactulose, polyethylene glycol
▫ Prokinetic agents
 Metoclopramide
▫ Rectal
 Suppositories, enemas, manual disimpaction
Nausea and Vomiting
 Nausea is the unpleasant subjective sensation as
a result from stimulation in the GI tract the
chemoreceptor trigger zone in the brain, the
vestibular apparatus and the cerebral cortex.
 Vomiting is the reflex that comes after
stimulation of one or more of these regions
 Associated with many advanced diseases
 Can also be a result of therapeutic interventions
 Thorough assessment of nausea and vomiting is
important to understand the cause and
treatment options
Nausea and Vomiting
• Non Pharmacologic
▫ Treat other symptoms (pain, short of breath,
constipation, anxiety)
▫ Avoid foods that are not pleasing to patient
▫ Relaxation and breathing, swallowing techniques
▫ Loose, unrestrictive clothing
▫ Avoid lying flat 2 hours after eating
▫ Encourage more frequent , small meals
Nausea and Vomiting
• Pharmacologic
▫ Gastrointestinal stimulation
 Diphenhydramine, antispasmodics, prokinetic
agents
▫ Vestibular
 Metoclopramide, scopalamine, meclizine
▫ Cerebral cortex (increased pressure)
 Steroids, neuroleptics
▫ Chemoreceptor trigger zone (drug toxins, disease)
 Evaluate causative agents (chemo, opioids)
 Dopamine agonists, serotonin antagonists,
anticholinergic drugs.
Case 3
• A 60 year old man with leukemia comes in with
new confusion and agitation. He is currently
undergoing chemotherapy and during his
treatment he started pulling out his iv lines and
became agitated. He usually lives at home with
his wife and daughter and they say he has
become more confused the last 2-3 weeks. They
are concerned he has dementia. He was recently
started on Diazepam for sleep.
• What is the correct treatment to first control his
symptoms
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A. STAT brain CT to rule out brain tumor
B. Antipsychotic to control agitation
C. Increase Diazepam to BID
D. Tell the family he likely has dementia and there
is no cure.
Answer B
• Antipsychotics for acute agitation to help calm
patient and complete work up.
• Need to rule out other causes of new decline
such as metastasis, metabolic
• Assess if medications need adjustment or if
medication is causing problems
• Delirium is an acute and fluctuation change in
mental status and alertness. Causes can be
multifactorial. Usually not permanent.
Delirium
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Occurs in up to 83% of patients near end of life
Reduced level of consciousness or memory loss
Disturbance of sleep wake cycle
Delusions, hallucinations or paranoia
Symptoms develop over a short period, tend to
wax and wane
• Symptoms can become worse if not treated
Delirium
• Medical assessment
▫ Examine new medical problems: infections,
dehydration, depression, anxiety, progression of
disease, metabolic abnormalities
• Non Pharmacologic Treatments
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Orientation
Increase sleep cycle at night
Ambulate and activity during the day
Vision and hearing aides
Increased socialization
• Pharmacologic Treatment
▫ Decrease or stop medication that can cause
problems
 Sedation medications, anticholinergics, sleep aides
▫ Antipsychotic medications
 Haloperidol or atypical antipsychotics
▫ Antidepressants or anxiolytics if indicated
▫ Short acting sleep agents or antipsychotics for
sleep prn until improved
Non Pain Symptom Management
• Many other symptoms that can cause distress in
severe illness or at end of life
• Assess by listening to patients report of
symptoms and monitoring
• Communication between the patient and family
with the medical care team
• Use team approach; including social workers,
chaplain, caregivers to give entire patient care.
Resources
• Berger, A.; Portenoy, R.; and Weissman, D. Principles and Practice of
Supportive Oncology. Lippincott-Raven. 1998.
• Doyle, D.; Hanks, G.W.C.; and MacDonald, N. Oxford Textbook of Palliative
Medicine. Oxford University Press. 2001.
• Betty R. Ferrell and Nessa Coyle , Textbook of Palliative Nursing, second edition
2010.
• O'Brien, T, Welsh J, Dunn FG. ABC of palliative care: Non-malignant
conditions. BMJ 1998; 316: 286-289.
• Storey, P, UNIPAC, Third Edition, BOOK 4: Management of Selected Non-Pain
Symptoms in the Terminally Ill, 2004.