Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms

Mike Marschke, MD

Mr. M - Chronic Smoker Mr. M, 78 YO, is a lifetime

smoker. Dyspnea began 5 years ago.

intubated twice in the past year.

Since last admission 2 mos ago always needs 2-3 l/min nasal cannula oxygen, even at rest.

He has lost 15 lbs, has a persistent cough, with gray phlegm

He is on steroids and nebulizers

What is Dyspnea? Subjective sense that you need to

breath, that you ‘hunger air.’ Mechanism

Respiratory Center of Medulla Chemo receptors sensing low O2, hi CO2 Mechano receptors (J receptors) in lung,

respiratory muscles, and diaphragm Vascular congestion-CHF

Cerebral Cortex

Measurements? pO2, pCO2, O2 sats Peak flows Pulmonary function tests measuring lung

volumes and flowPrognosis < 6 mos. : Class IV respiratory failure (= dyspnea at

rest) Frequent ER/hospital stays, recurring

pulmonary infections, intubations pO2 < 56mmHg, O2 sat < 89%, pCOs

>50

Dr. arrives Mr. K is sitting in a reclining chair. Feels “breathless” with minimal

exertion. Breathing is “heavy and suffocating”. No apparent precipitating infection etc.

Evaluation Physical exam- distant breath

sounds, coarse crackles at bases bilaterally, RR = 32 at rest, takes breathes in mid-sentence.

tachycardic at 100/min Recent Weight loss of 15lbs. in 6

months. 2+ edema bilateral lower

extremities

The Bargainer Has no wish to be “brutalized”. He

knows his emphysema will kill him someday.

He has executed a DNR He wants to feel better but does not

want to go back into the hospital.

What about CXR, labs?

Assess cause Complete assessment – may lead

to treatable condition. Pleural effusion Pneumothorax Anemia PE CHF Pneumonia

CXR Findings Mass occluding R bronchus Post obstruction atelectasis Treatment options

Bronchoscopy Radiation Supportive

Weigh risk/benefits and patient wishes

Oxygen Pulse oximetry not helpful – go on

symptoms Potent symbol of medical care Expensive, noisy, hot,

uncomfortable for some Fan may do just as well

Opioids Relief not related to respiratory rate No ethical or professional barriers Small doses Central and peripheral action Inhaled morphine works peripherally

but may induce bronchospasm

Anxiolytics Safe in combination with opioids

lorazepam 0.5-2 mg po q 1 h prn until settled then dose routinely q 4–6 h to keep

settled

Nonpharmacologic interventions . . . Reassure, work to manage anxiety Behavioral approaches, eg,

relaxation, distraction, hypnosis Other CAM – aromatherapies

(Eucalyptus, Bergomot), massage, healing touch

Limit the number of people in the room

Open window

Nonpharmacologic interventions . . . Eliminate environmental irritants Keep line of sight clear to outside Reduce the room temperature Avoid excessive temperatures

. . . Nonpharmacologic interventions Introduce humidity Reposition

elevate the head of the bed move patient to one side or other

Educate, support the family

4 Weeks Later in Hospice More dyspneic and semi-comatose Lots of upper airway noise with

wheezes more prevalent Gets agitated at times, cyanotic Difficult swallowing pills At times when sleeping family feels

he is choking to death

Final hours of care Educate the family- no surprises

Double effect? Oral secretions can be lessened by

keeping patient dry, scopalamine patch, levsin (anti-cholenergics)

Use opioids/benzodiazepams as needed Suctioning difficult for patient and likely

not to be able to get deep enough

Gastrointestinal Sx: EOL Anorexia 60-80% Xerostomia 55-70% Nausea 15-30% Vomiting 15-25% Constipation 50% Diarrhea <10%

Anorexia Corticosteroids Megestrol acetate Dronabinol Other causes – gastritis/PUD – PPIs,

early satiety/reflux – Reglan, oral thrush – anti-fungals.

Realize patient usually VERY comfortable with this!

Dry Mouth Hyposalivation

Mouth care and gum/candy, popsicles Artificial saliva Oral swabs/wash cloth

Pilocarpine 5mg tid Mucositis

Diphenhydramine, dexamethasone, lidocaine, and nystatin swish and swallow

Nausea/vomitingAnxiety, fear, anticipatory, psychologic factors,

increased intra-cranial pressureDopaminergic (narcotic – induced and many

others)

Serotinergic (chemo induced)

Histamine (labrynthitis, meds)

Vagally mediated (ulcers, masses, irritations…)

Reflux, gastritis, regurgitation, masses, ulcers, gastric outlet obstruction

Small bowel obstruction, impaction

Renal (pyelonephritis, stones), liver (hepatitis, cirrhosis), gall bladder, uterine…

A Mechanistic Approach Central –

Increased pressures (tumor, swelling, hydrocephalus) – steroids, RT, surgery

Anxiety, fear, anticipatory – benzodiazipines, psychotherapy

Chemo-trigger Receptor Zone (narcotics, other meds, many GI causes)

Anti-dopaminergics – prochlorperazine (compazine), haloperidol, droperidol, trimethobenzamide (Tigan), metoclopramide (Reglan), promethazine (phenergan)

Can be given PO, suppository, some IM/IV, some even in a paste form

A Mechanistic Approach Nausea Center (chemotherapy induced)

– Anti-serotinergics – ondansetron (Zofran),

granisetron (Kytril), dolasetron, palonosetron IV, PO, and expensive

Vestibular-ocular reflex (with vertigo) – Anti-histamines – Benedryl, Antivert, Atarax Anti-cholinergics - Scopolamine

Oro-pharyngeal vagal – lidocaine swish and swallow, treat the lesion

A Mechanistic Approach Gastro-esophageal –

Reflux/regurg – prokinetic agents like metoclopramide (reglan), H2 blockers/Proton pump inhibitors

Gastritis/ulcers – H2 blockers/PPIs Delayed gastric emptying (narcotics, DM)

– metoclopramide Gastric outlet obstruction – NG suction,

surgery

A Mechanistic Approach Intestinal

Obstruction – NG suction, surgery, NPO with Octreotide (Sandostatin)

Impaction – remember to check rectal exam – may need manual dis-impaction, enemas

Other organs – try to treat underlying cause if possible, may also respond to meds effecting CRZ

Other agents for nausea CAM – aromas (peppermint, ginger),

herbs (ginger, cola), mind-focusing (meditation), acupuncture

Dronabinol (marijuana) Combination suppositories/gels

BDR (Benadryl, Decadron, Reglan) Can add ativan, Tigan, compazine and

others

Constipation Defined:

hard, infrequent stools, needing to strain for 10 minutes

Uncomfortable feeling Incidence-

US nutrition- Male 8% Fem. 21% Hospice 80% Hospice on narcotics 90% Hospital 66%; Home 22%

Physiology Meal passes out of stomach into small

intestine, with the addition of gastric, pancreatic, and biliary secretions

Transit time is 1-2 hrs thru the small intestine, where digestion and absorption takes place

Large bowel transit time is 1-3 days, where bulk of water is removed and stool is formed

Final BM – when rectal ampula fills, increase abdomenal pressure, relax anal sphincter and “the brown river flows”

Constipation – causes: Medications

opioids calcium-channel

blockers anticholinergic

Decreased motility

Ileus Mechanical

obstruction Diet (lo fiber, hi

meat and starch)

Metabolic abnormalities (hi Ca)

Spinal cord compression

Dehydration Autonomic

dysfunction (DM) Malignancy

Opioids do Two things: Block Bowel (opioid receptors in

mesenteric plexus and bowel wall) Decrease propulsion Increase sphincter tone Increase bowel tone

Block pain/discomfort with packed bowel

Managementof constipation General measures

establish what is “normal”

regular toileting gastrocolic reflex

Check impaction – 98% in rectal vault – hard packed in stool to large to evacuate

Diet – hi fiber (greens, fruits, bran…), fluids, additive fibers (avoid with opioids at EOL)

Specific measures stimulants osmotics detergents lubricants large volume enemas

Stimulant laxatives Prune juice Senna (Senokot) Casanthranol (Pericolace) Bisacodyl (Dulcolax)

* Good preventatives with opioid use

Osmotic laxatives Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene Glycol (Miralax)

* Good add-ons if stimulants not enough with opioid induced constipation

Detergent laxatives(stool softeners)

Sodium docusate Calcium docusate Phosphosoda enema prn

Prokinetic agents Metoclopramide Cisapride

Lubricant stimulants Glycerin suppositories Oils

mineral peanut

Large-volume enemas Warm water Soap suds

Mr. L – 62 yo with Colon cancerMr. L has end-stage metastatic colon cancer,

diagnosed 6 months ago, with liver mets, ascites, carcinomatosis. He failed chemo, now in hospice for 2 wks. Over 2 days he has had persistent vomiting, unrelieved with compazine, steroids, ativan, with reglan making it worse. Over this time his abdomen has become very distended, he has crampy peri-umbilical pain, and he has not had a BM in 7 days. Lately, his vomit smells slightly fecal-like and is brown. He is miserable and wants to die now!

Mr. L – exam, tests?PE – In distress

- Abdomen distended and tense, tympanitic- Bowel sounds hyper- Abdomen diffusely tender- No stool in vault on rectal,

hemoccult negativeTests – KUB and upright abd x-ray shows

dilated loops of bowel and multiple air-fluid levels

Obstruction Vomiting 90+%, Pain 75% Hyperparastalsis Absent bowel sounds –

complications, perforation X-ray - dilated loops, air-fluid levels

on upright Contrast only if surgical candidate Consider Surgery

Conservative Management Antiemetics

Haloperidol, phenothiazines Scopalamine Octreotide - somatostatin Dexamethasone Ativan

…Conservative management Anticholinergics Analgesics:

Opioids, SQ/IV Consider NG suction (though very

uncomfortable) Keep PO intake limited (what goes

in must come up!)

Hospice emergencies Acute arterial bleed – either GI or pulmonary

source (though also could be peripheral artery/aorta)

From above – throwing up bright red blood, from below – bright red blood per rectum, from abd aorta – get acute rapid distention of abdomen (left side first), then cold pulseless feet

Usually the end catastrophic event but LOTS of anxiety, hard for family to watch, may have acute pain, then passes out

Morphine/ativan right away Red towels to hide the blood May need emergent hospitalization for family sake