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