Transcript Symptom Management in Palliative Care: Part 2

Symptom Management in
Palliative Care: Part 2
Scott Akin MD
[email protected]
Outline
• Pain control: That was part #1 of this
talk…e-mail me for a copy
• Depression
• Dyspnea
• Nausea and vomiting
• Anorexia
Depression in Palliative Care
• Common: numbers hover around 30%
• Misunderstood
– Myth that all dying patients “should” be
depressed, and it is a “normal” part of dying
• Underdiagnosed
– Clinicians fearful of upsetting patients
• Undertreated: only 10% in one study
Depression
• Sadness, grief, depressed mood, and feeling of
loss are all appropriate responses to dying…but
• Feelings of hopelessness, worthlessness,
helplessness, guilt, no desire for pleasure…are
NOT
• Bottom line:
– Depression is NOT a normal part of dying
– Depression is an illness, with symptoms that need to be
recognized and treated
How Do You Diagnose
Depression?
• DSM-IV….But not really set up for the medically
ill. Many depressive symptoms in medically ill
patients may be a result of their medical illness or
treatment.
• Careful interview.
• Consider simple 1-2 word screening tools:
– Are you depressed?
– Have you been depressed for most of the time for the
past 2 weeks?
– One of the above + loss of interest of usual activities.
Treatment of Depression
• First, relieve uncontrolled symptoms (pain,
nausea, dyspnea, etc.)
• Psychosocial interventions
– Psychotherapy
– CBT
• Pharmacologic interventions
Treatment of Depression: Drugs
• Not much data in palliative care setting
• As when treating depression in other settings, use
side effect profile
-Poor appetite/insomnia: Mirtazapine (Remeron)
-neuropathic/other pain: TCAs, duloxetine
(cymbalta), venlafaxine (effexor)
-Fatigue/psychomotor slowing: activating SSRI
(fluoxitine, venlafazine) or psychostimulants
• The “default” is probably an SSRI…unless
Depression in Last Weeks of Life
• SSRIs need 4-6 weeks to work, so why start one if
your patient is in last weeks of life?
• Instead, use pychostimulants such as
methylphenidate (Ritalin) or modafinil (Provigil)
– Very rapid onset of action (hours)
– Start low (2.5 of methlyphenidate daily) and titrate
upwards slowly
– You should see effect after 1-2 doses
Dyspnea
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“discomfort in breathing”
“breathlessness”
“Shortness of breath”
“uncomfortable awareness of breathing”
-------------------------------------------Dyspnea is a SUBJECTIVE sensation, for which the
standard of assessment is the patient’s self-report
(different from tachypnea which is an
OBJECTIVE, measured number)
Dyspnea
• Common in cancer patients (21-78%)
• Common in non cancer patients
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70% Dementia patients
68% terminal HIV/AIDS patients
65% CHF patients
56% COPD patients
50% ALS patients
36% CVA patients
Dyspnea Treatment
* Goal in terminally ill: Improve subjective
sensation expressed by patient
* In order to do that you must think about
cause…
– Sometimes interventions may be consistent
with patient’s goals of care…
– Other times they may not be…
Causes of Dyspnea
“BREATH AIR”
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Bronchospasm: Nebs and steroids?
Rales: Stop IVF, diuretics, antibiotics?
Effusions: Tap?
Airway obstruction: Change diet? Suction?
Thick secretions: Thin with:
-Atropine drops
– Nebulized saline (3%)
– Nebulized NAC (mucomyst)
Hemolgobin low: Transfusion?
-Glycopyrrolate
-scopolamine
(patch)
Causes of Dyspnea
“BREATHE AIR”
• Anxiety: *Sit upright, bedside fan, music
-Benzos if primary anxiety (if anxious because
sobopiates)
-antidepressants
• Interpersonal issues: emotional support
• Religious concerns: emotional support,
coordinate connection with
chaplain/spiritual advisor
Treatment of Dyspnea
• General Measures
– Proper positioning: vertical (if comfortable)…or
compromised lung down if horizontal
– Modify activity level (bathroom aids, wheelchair)
– Instruct on pursed lip breathing
– Fan (?stim V2, decreasing dyspnea perception)
– Open windows
– Avoid strong odors
– Keep room cool…humidifier
– Family/friends at bedside
Treatment of dyspnea
• Opioids: FIRST LINE
– Decrease receptor response to elevated CO2
– Vasodilitation/preload reduction
– Anxiolytic
-Nebulized opoids? Not yet…
• Which one to use? Probably doesn’t matter
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Morphine 2.5-5 mg PO q 4 hours
Hydrocodone 2.5-5mg PO q 4 hrs
Oxycodone 5mg PO q 4 hours
Hydromorphone 1-2mg PO q 4 hours
titrate
up
25-50%
q 12 hrs
Treatment of Dyspnea
• Oxygen: Interestingly, there is no clear evidence
that O2 works to relieve dyspnea any better than
air…even in hypoxemic patients (studies poor).
• Anxiolytics: Anxiety usually response to dyspnea.
– 4 of 5 RCTs found no benefit of benzos in dyspnea.
– Benzos more for refractory dyspnea worsened by
anxiety symptoms…(although some try when one
cannot titrate the opioid up further due to side effects).
– Lorazepam is probably 1st choice (fast onset of action,
and lasts 4-6 hours).
Next topic: Nausea and Vomiting
• What is the cause?
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Opioids
Other drugs
Constipation
PUD
Autonomic insufficiency
Metabolic abnormalities
Bowel obstruction
Increased ICP
CORRECT
THE
UNDERLYING
CAUSE
Nausea and Vomiting
• Opioid induced n/v (stimulation of CTZ)
– Mild nausea tends to be self-limited with time
– If not, or severe symptoms, change to other
opioid
– Consider long acting opioids to lessen the
potential fluctuation of levels which can
stimulate the CTZ
Nausea and Vomiting
• Opioid induced n/v
– Best drugs to treat:
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Haloperidol* (Haldol: THE most potent anti-dopinergic)
Prochlorperazine* (compazine: Potent anti-dopa, weak antihis)
Promethazine* (phenergan: Antihistamine, weak anti-dopa)
Scopolamine (especially if vestibular symptoms)
Diphenhydramine (benadryl….Careful in elderly)
• Metabolic induced n/v:
– Correct the metabolic derangement
– Best drugs to treat: Dopamine antagonists* as above
Nausea and Vomiting
• Constipation induced n/v
– First step: prevention
• Everyone on opioids gets DSS + cathartic (senna, ducolax)
• Hydration, physical activity
– If develops despite prophylaxis
• 1st r/o obstruction (rectal examdisimpaction helped by
mineral oil, glycerine supp, saline enemas)
• then treat with osmotic laxative (lactulose, PEG, Mag citrate)
Nausea and Vomiting
• Constipation induced n/v
– If patient too nauseated to take pos
• Sodium Phos (fleet) enema
• Bisocodyl suppository
– Refractory constipation induced n/v:
• Neostigmine
• opioid antagonists
– oral naloxone (?systemic absorption)
– SQ methylnaltrexone (selective peripheral antagonist)
Nausea/vomiting
• Dysmotilityabdominal distension (gastric stasis)
– Common in pts on opioids/anticholinergics
– Pts c/o early satietynausea (not fasting n/v)
• Metoclopramide (5-10mg PO qHS and qAC…or higher):
don’t use in renal failure, Parkinson’s
• DON’T USE Promethazine (phenergan)…which is an
anticholinergic
• Anorexia or increased ICP
– Dexamethasone (2-4mg PO bid-QID)
Nausea/vomiting
• Anticipatory nausea:
– Benzos: Lorezepam (0.5-2mg q 6 hrs)…avoid as single
agent (very weak antiemetic).
• Vestibular nausea:
– Scopolamine.
– Promethazine (Phenergan).
• Chemotherapy induced nausea/vomiting:
– 5HT3 antagonists (Ondansetron 4-8mg q 6 hours).
• Also in postoperative setting, or sometimes after other agents
have failed. Can cause mild headache, constipation.
Anorexia-Cachexia
• ACS (Anorexia Cachexia Syndrome)
– Loss of body weight (muscle mass and fat) in the
setting of cancer…predicts 3-6 month survival
------vs------
• General anorexia/cachexia at the end of life
– Reflects end result of metabolic, neuroendocrine
cascade (ketones, uremia, etc)…part of disease process
– Probably universal in the dying process
Anorexia-Cachexia
– Frequent cause of considerable concern for
families.
– Goals of treatment:
• Symptomatic not nutritional.
• Establish therapeutic relationship with
patient/family.
• Emphasis on social aspects of eating (pleasure,
nurturing, bonding experience).
• Education, Education, Education.
Anorexia/Cachexia
• Reversible causes?
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Pain
Nausea
Constipation
Depression
-Dry Mouth
-Candidiasis
-Gastritis
-Iatrogenic (XRT, chemo)
Anorexia/Cachexia
• Appetite stimulants.
– Rare to use…mostly when underlying cause
cannot be addressed, and in setting of being
consistent with patient’s goals of care.
– Consider time limited “therapeutic trial” in
selected patients after discussing goals of care
(goal might be to gain strength/independence
which can be reevaluated weekly for a few
weeks).
Appetite Stimulants
• Megesterol acetate (megace)
– Initially for AIDS associated wasting
– No change in muscle mass
– “Increases” weight (of >5% in only 15-20% of
patients) by increasing water retention and fat
deposition…over 6-8 weeks
– No survival benefit…risk of thrombosis
– If decide to use it, use elixir (cheaper, easier),
start at 400mg daily800mg daily
Appetite Stimulants
• Coricosteroids (dexamethasone, prednisone).
– Have temporary effect (up to a few weeks) on appetite
without increase in body mass…used mostly if
prognosis measured in weeks and if other target
symptoms might respond to steroids also (nausea,
bronchospasm, bone pain).
– May increase energy for brief period.
– Side effects! (mood swings, elevated BP, inc glucose).
– Stop if no benefit within a week or so.
Appetite Stimulants
• Others: Data mixed and routine use not
recommended.
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Eicosapentaenoic acid (omega 3 fish oil).
Thalidomide (in HIV/AIDS).
Melatonin.
NSAIDs.
Cannabinoids…(i.e. dronabinol).
Hydration at end of life
*Arguments for:
– Dehydrationelectrolyte
problemsconfusion.
– Dying patients more comfortable if hydrated (?)
– Withholding fluid might set precedent for
withholding other therapies which might be
appropriate (patients labeled “comfort care”).
Hydration at end of life
*Arguments against:
-No evidence fluids significantly prolong life.
-Interferes with acceptance of death.
-Less UOPless need for bed pain, urinal, foley.
-Less GI fluidless vomiting.
-Less pulm secretions/cough/congestion/edema
-Electrolyte disturbances/uremia may lead to
decreased level of consciousnessless suffering.
What to avoid
• “The tube feeding death spiral”
– Patient admited for massive stroke/urosepsis with
advanced underlying dementia
– Can’t swallow/aspirating/losing weight tube feeds
– Patient agitated with NGTremoves
– NGT replacedrestraints placed
– Aspiration PNA develops moved to ICU/pulse ox
– Repeat PNA 3-4 more times
– Family meeting
– Death
Summary
• Depression: recognize and treat at end of
life
– Don’t forget about psychostimilants
• Dyspnea = subjective sensation. Goal of
therapy is patient telling you they are better
– Treat underlying cause (if appropriate)
– Opiates are first line
Summary
• Nausea/vomiting:
– Consider cause before treating
– Most common cause is medication related
which is most effectively treated with
Dopamine antagonists:
– Haldol >Compazine > Phenergan
• Anorexia/cachexia
– Educate families
– Medications not that helpful