EPECEPECEPECEPEC EPECEPECEPECEPEC Common Physical Symptoms Common Physical Symptoms Module 10 The...

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EEPPEECC

Common Physical Symptoms

Module 10Module 10Module 10Module 10

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

ObjectivesObjectives

Know general guidelines for Know general guidelines for managing nonpain symptomsmanaging nonpain symptoms

Understand how the principles of Understand how the principles of intended / unintended consequences intended / unintended consequences and double effect apply to symptom and double effect apply to symptom managementmanagement

Know the assessment, management Know the assessment, management of common physical symptomsof common physical symptoms

Know general guidelines for Know general guidelines for managing nonpain symptomsmanaging nonpain symptoms

Understand how the principles of Understand how the principles of intended / unintended consequences intended / unintended consequences and double effect apply to symptom and double effect apply to symptom managementmanagement

Know the assessment, management Know the assessment, management of common physical symptomsof common physical symptoms

General management guidelines . . .General management guidelines . . . History, physical examinationHistory, physical examination

Conceptualize likely causesConceptualize likely causes

Discuss treatment options, assist Discuss treatment options, assist with decision makingwith decision making

History, physical examinationHistory, physical examination

Conceptualize likely causesConceptualize likely causes

Discuss treatment options, assist Discuss treatment options, assist with decision makingwith decision making

. . . General management guidelines. . . General management guidelines Provide ongoing patient, family Provide ongoing patient, family

education, supporteducation, support

Involve members of the entire Involve members of the entire interdisciplinary teaminterdisciplinary team

Reassess frequentlyReassess frequently

Provide ongoing patient, family Provide ongoing patient, family education, supporteducation, support

Involve members of the entire Involve members of the entire interdisciplinary teaminterdisciplinary team

Reassess frequentlyReassess frequently

Intended vs unintended consequencesIntended vs unintended consequences Primary intent dictates ethical Primary intent dictates ethical

medical practicemedical practice

Primary intent dictates ethical Primary intent dictates ethical medical practicemedical practice

Breathlessness (dyspnea) . . .Breathlessness (dyspnea) . . . May be described asMay be described as

shortness of breathshortness of breath

a smothering feelinga smothering feeling

inability to get enough airinability to get enough air

suffocationsuffocation

May be described asMay be described as

shortness of breathshortness of breath

a smothering feelinga smothering feeling

inability to get enough airinability to get enough air

suffocationsuffocation

. . . Breathlessness (dyspnea). . . Breathlessness (dyspnea) The only reliable measure is patient The only reliable measure is patient

self-reportself-report

Respiratory rate, pORespiratory rate, pO22, blood gas , blood gas

determinations DO NOT correlate determinations DO NOT correlate with the feeling of breathlessnesswith the feeling of breathlessness

Prevalence in the life-threateningly Prevalence in the life-threateningly ill: 12 – 74%ill: 12 – 74%

The only reliable measure is patient The only reliable measure is patient self-reportself-report

Respiratory rate, pORespiratory rate, pO22, blood gas , blood gas

determinations DO NOT correlate determinations DO NOT correlate with the feeling of breathlessnesswith the feeling of breathlessness

Prevalence in the life-threateningly Prevalence in the life-threateningly ill: 12 – 74%ill: 12 – 74%

Causes of breathlessnessCauses of breathlessness

AnxietyAnxiety

Airway obstructionAirway obstruction

BronchospasmBronchospasm

HypoxemiaHypoxemia

Pleural effusionPleural effusion

PneumoniaPneumonia

Pulmonary edemaPulmonary edema

AnxietyAnxiety

Airway obstructionAirway obstruction

BronchospasmBronchospasm

HypoxemiaHypoxemia

Pleural effusionPleural effusion

PneumoniaPneumonia

Pulmonary edemaPulmonary edema

Pulmonary Pulmonary embolismembolism

Thick secretionsThick secretions

AnemiaAnemia

MetabolicMetabolic

Family / financial / Family / financial / legal / spiritual / legal / spiritual / practical issuespractical issues

Pulmonary Pulmonary embolismembolism

Thick secretionsThick secretions

AnemiaAnemia

MetabolicMetabolic

Family / financial / Family / financial / legal / spiritual / legal / spiritual / practical issuespractical issues

Managementof breathlessnessManagementof breathlessness Treat the underlying causeTreat the underlying cause

Symptomatic managementSymptomatic management

oxygenoxygen

opioidsopioids

anxiolyticsanxiolytics

nonpharmacologic interventionsnonpharmacologic interventions

Treat the underlying causeTreat the underlying cause

Symptomatic managementSymptomatic management

oxygenoxygen

opioidsopioids

anxiolyticsanxiolytics

nonpharmacologic interventionsnonpharmacologic interventions

OxygenOxygen

Pulse oximetry not helpfulPulse oximetry not helpful

Potent symbol of medical carePotent symbol of medical care

ExpensiveExpensive

Fan may do just as wellFan may do just as well

Pulse oximetry not helpfulPulse oximetry not helpful

Potent symbol of medical carePotent symbol of medical care

ExpensiveExpensive

Fan may do just as wellFan may do just as well

OpioidsOpioids

Relief not related to respiratory rateRelief not related to respiratory rate

No ethical or professional barriersNo ethical or professional barriers

Small dosesSmall doses

Central and peripheral actionCentral and peripheral action

Relief not related to respiratory rateRelief not related to respiratory rate

No ethical or professional barriersNo ethical or professional barriers

Small dosesSmall doses

Central and peripheral actionCentral and peripheral action

AnxiolyticsAnxiolytics

Safe in combination with opioidsSafe in combination with opioids

lorazepamlorazepam

0.5-2 mg po q 1 h prn until 0.5-2 mg po q 1 h prn until settledsettled

then dose routinely q 4–6 h to then dose routinely q 4–6 h to keep settledkeep settled

Safe in combination with opioidsSafe in combination with opioids

lorazepamlorazepam

0.5-2 mg po q 1 h prn until 0.5-2 mg po q 1 h prn until settledsettled

then dose routinely q 4–6 h to then dose routinely q 4–6 h to keep settledkeep settled

Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Reassure, work to manage anxietyReassure, work to manage anxiety

Behavioral approaches, eg, Behavioral approaches, eg, relaxation, distraction, hypnosisrelaxation, distraction, hypnosis

Limit the number of people in the Limit the number of people in the roomroom

Open windowOpen window

Reassure, work to manage anxietyReassure, work to manage anxiety

Behavioral approaches, eg, Behavioral approaches, eg, relaxation, distraction, hypnosisrelaxation, distraction, hypnosis

Limit the number of people in the Limit the number of people in the roomroom

Open windowOpen window

Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Eliminate environmental irritantsEliminate environmental irritants

Keep line of sight clear to outside Keep line of sight clear to outside

Reduce the room temperatureReduce the room temperature

Avoid chilling the patientAvoid chilling the patient

Eliminate environmental irritantsEliminate environmental irritants

Keep line of sight clear to outside Keep line of sight clear to outside

Reduce the room temperatureReduce the room temperature

Avoid chilling the patientAvoid chilling the patient

. . . Nonpharmacologic interventions. . . Nonpharmacologic interventions Introduce humidityIntroduce humidity

RepositionReposition

elevate the head of the bedelevate the head of the bed

move patient to one side or othermove patient to one side or other

Educate, support the familyEducate, support the family

Introduce humidityIntroduce humidity

RepositionReposition

elevate the head of the bedelevate the head of the bed

move patient to one side or othermove patient to one side or other

Educate, support the familyEducate, support the family

Nausea / vomitingNausea / vomiting

Nausea Nausea

subjective sensationsubjective sensation

stimulation stimulation

gastrointestinal lining, CTZ, gastrointestinal lining, CTZ, vestibular apparatus, cerebral vestibular apparatus, cerebral cortexcortex

VomitingVomiting

neuromuscular reflexneuromuscular reflex

Nausea Nausea

subjective sensationsubjective sensation

stimulation stimulation

gastrointestinal lining, CTZ, gastrointestinal lining, CTZ, vestibular apparatus, cerebral vestibular apparatus, cerebral cortexcortex

VomitingVomiting

neuromuscular reflexneuromuscular reflex

Causesof nausea / vomitingCausesof nausea / vomiting MMetastasesetastases

MMeningeal eningeal irritationirritation

MMovementovement

MMental anxietyental anxiety

MMedicationsedications

MMucosal irritationucosal irritation

MMetastasesetastases

MMeningeal eningeal irritationirritation

MMovementovement

MMental anxietyental anxiety

MMedicationsedications

MMucosal irritationucosal irritation

MMechanical echanical obstructionobstruction

MMotilityotility

MMetabolicetabolic

MMicrobesicrobes

MMyocardialyocardial

MMechanical echanical obstructionobstruction

MMotilityotility

MMetabolicetabolic

MMicrobesicrobes

MMyocardialyocardial

Pathophysiologyof nausea / vomitingPathophysiologyof nausea / vomiting

CortexCortexCortexCortex

Vestibular Vestibular apparatusapparatusVestibular Vestibular apparatusapparatus

GI tractGI tractGI tractGI tract

ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)

NeurotransmittersNeurotransmitters SerotoninSerotonin DopamineDopamine AcetylcholineAcetylcholine HistamineHistamine

Vomiting centerVomiting center

Managementof nausea / vomitingManagementof nausea / vomiting Dopamine Dopamine

antagonistsantagonists

AntihistaminesAntihistamines

AnticholinergicsAnticholinergics

Serotonin Serotonin antagonistsantagonists

Dopamine Dopamine antagonistsantagonists

AnticholinergicsAnticholinergics

Serotonin Serotonin antagonistsantagonists

Prokinetic agentsProkinetic agents

AntacidsAntacids

Cytoprotective Cytoprotective agentsagents

Other medicationsOther medications

AntacidsAntacids

Cytoprotective Cytoprotective agentsagents

Dopamine antagonistsDopamine antagonists HaloperidolHaloperidol ProchlorperazineProchlorperazine Droperidol Droperidol ThiethylperazineThiethylperazine Promethazine Promethazine Perphenazine Perphenazine TrimethobenzamideTrimethobenzamide MetoclopramideMetoclopramide

HaloperidolHaloperidol ProchlorperazineProchlorperazine Droperidol Droperidol ThiethylperazineThiethylperazine Promethazine Promethazine Perphenazine Perphenazine TrimethobenzamideTrimethobenzamide MetoclopramideMetoclopramide

Histamine antagonists (antihistamines)Histamine antagonists (antihistamines)

DiphenhydramineDiphenhydramine

MeclizineMeclizine

HydroxyzineHydroxyzine

DiphenhydramineDiphenhydramine

MeclizineMeclizine

HydroxyzineHydroxyzine

Acetylcholine antagonists(anticholinergics)Acetylcholine antagonists(anticholinergics)

ScopolamineScopolamine ScopolamineScopolamine

Serotonin antagonistsSerotonin antagonists

OndansetronOndansetron

GranisetronGranisetron

OndansetronOndansetron

GranisetronGranisetron

MetoclopramideMetoclopramide

CisaprideCisapride

MetoclopramideMetoclopramide

CisaprideCisapride

AntacidsAntacids AntacidsAntacids

HH22 receptor antagonists receptor antagonists

cimetidinecimetidine

famotidinefamotidine

ranitidineranitidine

Proton pump inhibitorsProton pump inhibitorsomeprazoleomeprazole

lansoprazolelansoprazole

AntacidsAntacids

HH22 receptor antagonists receptor antagonists

cimetidinecimetidine

famotidinefamotidine

ranitidineranitidine

Proton pump inhibitorsProton pump inhibitorsomeprazoleomeprazole

lansoprazolelansoprazole

Cytoprotective agentsCytoprotective agents

MisoprostolMisoprostol

Proton pump inhibitors (omeprazole, Proton pump inhibitors (omeprazole, lansoprazole)lansoprazole)

MisoprostolMisoprostol

Proton pump inhibitors (omeprazole, Proton pump inhibitors (omeprazole, lansoprazole)lansoprazole)

DexamethasoneDexamethasone

TetrahydrocannabinolTetrahydrocannabinol

LorazepamLorazepam

OctreotideOctreotide

TetrahydrocannabinolTetrahydrocannabinol

LorazepamLorazepam

ConstipationConstipation MedicationsMedications

opioidsopioids

calcium-channel calcium-channel blockersblockers

anticholinergicanticholinergic

Decreased motilityDecreased motility

IleusIleus

Mechanical Mechanical obstructionobstruction

MedicationsMedications

opioidsopioids

calcium-channel calcium-channel blockersblockers

anticholinergicanticholinergic

Decreased motilityDecreased motility

IleusIleus

Mechanical Mechanical obstructionobstruction

Metabolic Metabolic abnormalitiesabnormalities

Spinal cord Spinal cord compressioncompression

DehydrationDehydration

Autonomic Autonomic dysfunctiondysfunction

MalignancyMalignancy

Metabolic Metabolic abnormalitiesabnormalities

Spinal cord Spinal cord compressioncompression

DehydrationDehydration

Autonomic Autonomic dysfunctiondysfunction

MalignancyMalignancy

Managementof constipationManagementof constipation General measuresGeneral measures

establish what is establish what is “normal”“normal”

regular toiletingregular toileting

gastrocolic reflexgastrocolic reflex

General measuresGeneral measures

establish what is establish what is “normal”“normal”

regular toiletingregular toileting

gastrocolic reflexgastrocolic reflex

Specific measuresSpecific measures

stimulantsstimulants

osmoticsosmotics

detergentsdetergents

lubricantslubricants

large volume large volume enemasenemas

Specific measuresSpecific measures

stimulantsstimulants

osmoticsosmotics

detergentsdetergents

lubricantslubricants

large volume large volume enemasenemas

Stimulant laxativesStimulant laxatives

Prune juice Prune juice

Senna Senna

Casanthranol Casanthranol

BisacodylBisacodyl

Prune juice Prune juice

Senna Senna

Casanthranol Casanthranol

BisacodylBisacodyl

Osmotic laxativesOsmotic laxatives

Lactulose or sorbitol Lactulose or sorbitol

Milk of magnesia (other Mg salts) Milk of magnesia (other Mg salts)

Magnesium citrateMagnesium citrate

Lactulose or sorbitol Lactulose or sorbitol

Milk of magnesia (other Mg salts) Milk of magnesia (other Mg salts)

Magnesium citrateMagnesium citrate

Detergent laxatives(stool softeners)Detergent laxatives(stool softeners)

Sodium docusateSodium docusate

Calcium docusateCalcium docusate

Phosphosoda enema prnPhosphosoda enema prn

Sodium docusateSodium docusate

Calcium docusateCalcium docusate

Phosphosoda enema prnPhosphosoda enema prn

Metoclopramide Metoclopramide

Cisapride Cisapride

Metoclopramide Metoclopramide

Cisapride Cisapride

Lubricant stimulantsLubricant stimulants

Glycerin suppositoriesGlycerin suppositories

OilsOils

mineralmineral

peanutpeanut

Glycerin suppositoriesGlycerin suppositories

OilsOils

mineralmineral

peanutpeanut

Large-volume enemasLarge-volume enemas

Warm waterWarm water

Soap sudsSoap suds

Warm waterWarm water

Soap sudsSoap suds

Constipationfrom opioids . . .Constipationfrom opioids . . . Occurs with all opioidsOccurs with all opioids

Pharmacologic tolerance developed Pharmacologic tolerance developed slowly, or not at allslowly, or not at all

Dietary interventions alone usually Dietary interventions alone usually not sufficientnot sufficient

Avoid bulk-forming agents in Avoid bulk-forming agents in debilitated patientsdebilitated patients

Occurs with all opioidsOccurs with all opioids

Pharmacologic tolerance developed Pharmacologic tolerance developed slowly, or not at allslowly, or not at all

Dietary interventions alone usually Dietary interventions alone usually not sufficientnot sufficient

Avoid bulk-forming agents in Avoid bulk-forming agents in debilitated patientsdebilitated patients

. . . Constipationfrom opioids. . . Constipationfrom opioids Combination stimulant / softeners Combination stimulant / softeners

are useful first-line medicationsare useful first-line medications

casanthranol + docusate sodiumcasanthranol + docusate sodium

senna + docusate sodiumsenna + docusate sodium

Combination stimulant / softeners Combination stimulant / softeners are useful first-line medicationsare useful first-line medications

casanthranol + docusate sodiumcasanthranol + docusate sodium

senna + docusate sodiumsenna + docusate sodium

Causes of diarrheaCauses of diarrhea InfectionsInfections GI bleedingGI bleeding MalabsorptionMalabsorption MedicationsMedications ObstructionObstruction Overflow incontinenceOverflow incontinence StressStress

InfectionsInfections GI bleedingGI bleeding MalabsorptionMalabsorption MedicationsMedications ObstructionObstruction Overflow incontinenceOverflow incontinence StressStress

Management of diarrheaManagement of diarrhea

Establish normal bowel patternEstablish normal bowel pattern

Avoid gas-forming foodsAvoid gas-forming foods

Increase bulkIncrease bulk

Transient, mild diarrheaTransient, mild diarrhea

attapulgiteattapulgite

bismuth saltsbismuth salts

Establish normal bowel patternEstablish normal bowel pattern

Avoid gas-forming foodsAvoid gas-forming foods

Increase bulkIncrease bulk

Transient, mild diarrheaTransient, mild diarrhea

attapulgiteattapulgite

bismuth saltsbismuth salts

Managementof persistent diarrheaManagementof persistent diarrhea LoperamideLoperamide

Diphenoxylate / atropineDiphenoxylate / atropine

Tincture of opiumTincture of opium

LoperamideLoperamide

Diphenoxylate / atropineDiphenoxylate / atropine

Tincture of opiumTincture of opium

Anorexia / cachexiaAnorexia / cachexia

Loss of appetiteLoss of appetite

Loss of weightLoss of weight

Loss of appetiteLoss of appetite

Loss of weightLoss of weight

Managementof anorexia / cachexia . . .Managementof anorexia / cachexia . . . Assess, manage comorbid Assess, manage comorbid

conditionsconditions

Educate, supportEducate, support

Favorite foods / nutritional Favorite foods / nutritional supplementssupplements

Assess, manage comorbid Assess, manage comorbid conditionsconditions

Educate, supportEducate, support

Favorite foods / nutritional Favorite foods / nutritional supplementssupplements

. . . Managementof anorexia / cachexia. . . Managementof anorexia / cachexia AlcoholAlcohol

Megestrol acetateMegestrol acetate

Tetrahydrocannabinol (THC)Tetrahydrocannabinol (THC)

AndrogensAndrogens

AlcoholAlcohol

Megestrol acetateMegestrol acetate

Tetrahydrocannabinol (THC)Tetrahydrocannabinol (THC)

AndrogensAndrogens

Managementof fatigue / weakness . . .Managementof fatigue / weakness . . . Promote energy conservationPromote energy conservation Evaluate medicationsEvaluate medications Optimize fluid, electrolyte intakeOptimize fluid, electrolyte intake Permission to restPermission to rest Clarify role of underlying illness Clarify role of underlying illness Educate, support patient, familyEducate, support patient, family Include other disciplinesInclude other disciplines

Promote energy conservationPromote energy conservation Evaluate medicationsEvaluate medications Optimize fluid, electrolyte intakeOptimize fluid, electrolyte intake Permission to restPermission to rest Clarify role of underlying illness Clarify role of underlying illness Educate, support patient, familyEducate, support patient, family Include other disciplinesInclude other disciplines

. . . Managementof fatigue / weakness. . . Managementof fatigue / weakness Dexamethasone Dexamethasone

feeling of well-being, increased energyfeeling of well-being, increased energy

effect may wane after 4-6 weekseffect may wane after 4-6 weeks

continue until deathcontinue until death

MethylphenidateMethylphenidate

Dexamethasone Dexamethasone

feeling of well-being, increased energyfeeling of well-being, increased energy

effect may wane after 4-6 weekseffect may wane after 4-6 weeks

continue until deathcontinue until death

MethylphenidateMethylphenidate

Fluid balance / edema . . .Fluid balance / edema . . .

Frequently associated with advanced Frequently associated with advanced illnessillness

Hypoalbuminemia Hypoalbuminemia decreased decreased oncotic pressureoncotic pressure

Venous or lymphatic obstruction Venous or lymphatic obstruction may contributemay contribute

Frequently associated with advanced Frequently associated with advanced illnessillness

Hypoalbuminemia Hypoalbuminemia decreased decreased oncotic pressureoncotic pressure

Venous or lymphatic obstruction Venous or lymphatic obstruction may contributemay contribute

. . . Fluid balance / edema. . . Fluid balance / edema

Limit or avoid IV fluidsLimit or avoid IV fluids

Urine output will be lowUrine output will be low

Drink some fluids with saltDrink some fluids with salt

Fragile skinFragile skin

Limit or avoid IV fluidsLimit or avoid IV fluids

Urine output will be lowUrine output will be low

Drink some fluids with saltDrink some fluids with salt

Fragile skinFragile skin

SkinSkin

HygieneHygiene

ProtectionProtection

SupportSupport

HygieneHygiene

ProtectionProtection

SupportSupport

Pressure (decubitus) ulcersPressure (decubitus) ulcers Prolonged pressureProlonged pressure

InactivityInactivity

Closely associated with mortalityClosely associated with mortality

Easier to prevent than treatEasier to prevent than treat

Prolonged pressureProlonged pressure

InactivityInactivity

Closely associated with mortalityClosely associated with mortality

Easier to prevent than treatEasier to prevent than treat

OdorsOdors Topical and / or systemic antibioticsTopical and / or systemic antibiotics

metronidazolemetronidazole

silver sulfadiazinesilver sulfadiazine

Kitty litterKitty litter

Activated charcoalActivated charcoal

VinegarVinegar

Burning candlesBurning candles

Topical and / or systemic antibioticsTopical and / or systemic antibiotics

metronidazolemetronidazole

silver sulfadiazinesilver sulfadiazine

Kitty litterKitty litter

Activated charcoalActivated charcoal

VinegarVinegar

Burning candlesBurning candles

InsomniaInsomnia

Assessment of sleepAssessment of sleep

Other unrelieved symptomsOther unrelieved symptoms

Use family to help assessUse family to help assess

Assessment of sleepAssessment of sleep

Other unrelieved symptomsOther unrelieved symptoms

Use family to help assessUse family to help assess

Management of insomnia . . .Management of insomnia . . . Regular sleep schedule, avoid Regular sleep schedule, avoid

staying in bedstaying in bed Avoid caffeine, assess alcohol intakeAvoid caffeine, assess alcohol intake Cognitive / physical stimulationCognitive / physical stimulation Avoid overstimulationAvoid overstimulation Control pain during the nightControl pain during the night Relaxation, imageryRelaxation, imagery

Regular sleep schedule, avoid Regular sleep schedule, avoid staying in bedstaying in bed

Avoid caffeine, assess alcohol intakeAvoid caffeine, assess alcohol intake Cognitive / physical stimulationCognitive / physical stimulation Avoid overstimulationAvoid overstimulation Control pain during the nightControl pain during the night Relaxation, imageryRelaxation, imagery

. . . Managementof insomnia. . . Managementof insomnia AntihistaminesAntihistamines

BenzodiazepinesBenzodiazepines

NeurolepticsNeuroleptics

Sedating antidepressant (trazodone)Sedating antidepressant (trazodone)

Careful titrationCareful titration

Attention to adverse effectsAttention to adverse effects

BenzodiazepinesBenzodiazepines

NeurolepticsNeuroleptics

Sedating antidepressant (trazodone)Sedating antidepressant (trazodone)

Careful titrationCareful titration

Attention to adverse effectsAttention to adverse effects

EEPPEECC

EEPPEECC Common Physical Common Physical

Symptoms Symptoms

SummarySummary

Common Physical Common Physical Symptoms Symptoms

SummarySummary

EPECEPECEPECEPEC EPECEPECEPECEPEC Common Physical Symptoms Common Physical Symptoms Module 10 The...

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