Transcript What symptoms?

END-OF-LIFE CARE:
Module 5
Non-Pain Symptom Management
http://www.growthhouse.org/stanford
Module #5
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.
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #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
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Module #5
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?
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Module #5
From the Patient’s Perspective
A symptom is what is bothersome
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Module #5
Symptom Analysis Checklist
Physiological Factors
Mental Factors
• Local
• Cognitive
• Central
• Affective
• Spiritual
http://www.growthhouse.org/stanford
Module #5
Skills Practice: Patient with
pain symptoms due to
metastatic bone cancer
Physiological factors
Mental Factors
Local:
Cognitive:
Central:
Affective:
Spiritual:
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Module #5
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
http://www.growthhouse.org/stanford
Module #5
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?
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Module #5
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
http://www.growthhouse.org/stanford
Module #5
A Central Final Pathway for
Nausea
(Dopamine, Serotonin)
(???)
CNS
CTZ
VOMIT CENTER
(Acetylcholine,
Histamine)
Vestibular
Apparatus
(Acetylcholine,
Histamine)
http://www.growthhouse.org/stanford
GI Tract
(Acetylcholine, Histamine,
Serotonin + mechanoreceptors)
Module #5
Receptor Affinity Common
Antiemetics
Drug
Scopalomine
Promethazine
Prochlorperazine
Chlorpromazine
Metoclopramide
Haloperidol
Dopamine
>10,000
240
15
25
270
4.2
Receptors
Musc. Chol.
.08
21
2100
130
>10,000
>10,000
Histamine
>10,000
2.9
100
28
1,000
1,600
Potency: K1 (nanomolar)
The lower the number, the stronger this agent is at blocking this receptor
Adapted from Peroutka and Snyder, 1982
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Module #5
Causes of Nausea & Vomiting
• Vestibular
• Obstruction
• Mind
• Dysmotility
• Infection (irritation)
• Toxins (taste and other senses)
http://www.growthhouse.org/stanford
Module #5
Vestibular Apparatus
• Nausea with head movement
• Medicated by acetylcholine and histamine
receptors
• Most anticholinergic, antihistamine drugs will
help
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
Mind
• Memory, meaning, and emotions can be very
powerful
• Manipulate taste and other senses
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Module #5
Dysmotility
• Multiple causes
– Upper intestinal dysmotility is very common
• Prokinetics:
– Metoclopramide (upper only)
– Senna (lower only)
http://www.growthhouse.org/stanford
Module #5
Infection/Irritation
• Mediated through chemoreceptors
• Gut and adjacent organ inflammation can trigger
• Anticholinergic/antihistaminic medications can
help
http://www.growthhouse.org/stanford
Module #5
Toxins
• Most important source: medications
• Various mechanisms of inducing nausea
• Treatment depends on mechanism of action
http://www.growthhouse.org/stanford
Module #5
Opioid-Related Nausea
• Incidence of dysmotility caused by opioids may
be underestimated
• Haloperidol recommended for nausea related to
chemoreceptor trigger zone (CTZ)
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Module #5
5HT3 Antagonists
• May have a variety of uses
• Minimally tested outside of their use in
chemotherapy-related nausea
• Expensive
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Module #5
Symptom Analysis Checklist
• Physiological Factors
– Local
– Central
• Mental
– Cognitive
– Affective
– Spiritual
http://www.growthhouse.org/stanford
Module #5
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?
http://www.growthhouse.org/stanford
Module #5
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?
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
‘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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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.
http://www.growthhouse.org/stanford
Module #5
Definitions
• Cachexia = physical wasting
• Anorexia = lack of appetite
• Asthenia = weakness, fatigue
http://www.growthhouse.org/stanford
Module #5
Physiological Mechanisms
• Complex physiology
• Best studied in cancer
• Key finding: Not the same as starvation
– Significant physiological differences
• Often not reversed by artificial feeding
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
Artificial Hydration at the End
of Life is Controversial
http://www.growthhouse.org/stanford
Module #5
Brainstorm
• What are some arguments on both sides of the
EOL artificial hydration controversy?
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Module #5
Some Arguments...
In Favor:
Against:
• Minimum standard of care
• ? Greater comfort
• ? Less confusion,
restlessness
• 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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5
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
http://www.growthhouse.org/stanford
Module #5