Physicial Symptoms

7/28/2019 Physicial Symptoms

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AnorexiaAnorexiaThe Palliative ResponseThe Palliative Response

F. Amos Bailey, M.D.F. Amos Bailey, M.D.


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Anorexia is a SymptomAnorexia is a Symptom

Anorexia is a common symptomAnorexia is a common symptom

at Lifes Endat Lifes End

Decreased intake is nearly universalDecreased intake is nearly universal

in the last few weeks to days of lifein the last few weeks to days of life


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The Role of theThe Role of the

PhysicianPhysician Look for reversible causesLook for reversible causes Consider the use of appetite stimulantsConsider the use of appetite stimulants Provide accurate and helpful informationProvide accurate and helpful information Help family members identify alternativeHelp family members identify alternative

methods of expressing lovemethods of expressing love

Ensure that any IV or tube feedings areEnsure that any IV or tube feedings aresafe, effective and consistent with goalssafe, effective and consistent with goalsof careof care


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Dietary ManagementDietary Management

Involve the patient in menu planningInvolve the patient in menu planning

Offer small portions of patients favoriteOffer small portions of patients favorite

foodsfoods

Offer easy-to-swallow foodsOffer easy-to-swallow foods

Try sweetsTry sweets

Avoid foods with strong smells, flavor orAvoid foods with strong smells, flavor or

spices, unless patient requestsspices, unless patient requests


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Responding to FamilyResponding to Family

ConcernsConcerns

Family members and caregivers are oftenFamily members and caregivers are oftenmuch more concerned than the patientmuch more concerned than the patientabout lack of appetite and may harass theabout lack of appetite and may harass thepatient about decreased intakepatient about decreased intake

Anticipate family concerns and initiateAnticipate family concerns and initiatefamily discussion about decreasedfamily discussion about decreasedappetiteappetite

Be prepared to discuss and review thisBe prepared to discuss and review thissymptom every time you meet with familysymptom every time you meet with family

Demonstrate willingness within reason toDemonstrate willingness within reason to

look for reversible causes and to uselook for reversible causes and to usea etite stimulants


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Educating Patient andEducating Patient and

FamilyFamily

Educate about natural progression ofEducate about natural progression ofthe underlying illness and its effect onthe underlying illness and its effect on

appetiteappetite

Anorexia is a symptom of the diseaseAnorexia is a symptom of the disease

The patient is not starvingThe patient is not starving

Forced feeding often causes discomfortForced feeding often causes discomfort

Artificial feeding usually does not prolongArtificial feeding usually does not prolong

lifelife

and may shorten itand may shorten it

Patients are usually not uncomfortablePatients are usually not uncomfortable


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Reversible Causes ofReversible Causes of

AnorexiaAnorexia

Differential ConsiderationsDifferential Considerations

Poorly controlled pain and non-painPoorly controlled pain and non-painsymptomssymptoms

Nausea and vomitingNausea and vomiting

GI dysmotility (gastroparesis)GI dysmotility (gastroparesis) Oral infections such as thrush or herpesOral infections such as thrush or herpes

simplexsimplex

Xerostomia (dry mouth)Xerostomia (dry mouth)


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Reversible Causes ofReversible Causes of

AnorexiaAnorexia

Differential ConsiderationsDifferential Considerations

Constipation and urinary retentionConstipation and urinary retention Medications such iron supplementsMedications such iron supplements

Chemotherapy and radiationChemotherapy and radiation

Depression and anxietyDepression and anxiety Gastritis and Peptic Ulcer DiseaseGastritis and Peptic Ulcer Disease


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Consider an AppetiteConsider an Appetite

StimulantStimulant

AlcoholAlcohol Wine, sherry and beer have significantWine, sherry and beer have significant

calories and are well known appetitecalories and are well known appetite

stimulantsstimulants

Consider using if consistent with cultureConsider using if consistent with culture

and heritage and if no history of pastand heritage and if no history of pastalcohol abusealcohol abuse

Many people who had used alcoholMany people who had used alcohol

routinely before they became ill have theroutinely before they became ill have the


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StimulantStimulant

Cyproheptadine (Periactin)Cyproheptadine (Periactin) This antihistamine has the side effect ofThis antihistamine has the side effect of

weight gainweight gain

Has been used to treat anorexia nervosaHas been used to treat anorexia nervosa

Not highly effective and may be moreNot highly effective and may be moreplacebo effect than active drugplacebo effect than active drug

Is not likely to be helpful at the EOLIs not likely to be helpful at the EOL


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StimulantStimulant

Megestrol (Megase)Megestrol (Megase) Approved for the treatment of AIDSApproved for the treatment of AIDS

WastingWasting

Dose for wasting is megestrol suspensionDose for wasting is megestrol suspension

800mg QD800mg QD

Expensive - approximately $350/monthExpensive - approximately $350/month

Major side effects areMajor side effects are

Pulmonary embolismPulmonary embolism


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StimulantStimulant

Megestrol (Megase)Megestrol (Megase)

In patients with cancer, the use ofIn patients with cancer, the use of

megestrol was not associated with anymegestrol was not associated with anydocumented improvement in QOL ordocumented improvement in QOL or

survivalsurvival

Usually not recommend for anorexia atUsually not recommend for anorexia at

EOLEOL


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StimulantStimulant

Dexamethasone (Decadron)Dexamethasone (Decadron)Dose 0f 2-4mg at breakfast and lunchDose 0f 2-4mg at breakfast and lunch

Can tell within a few days to a week ifCan tell within a few days to a week ifeffectiveeffective

InexpensiveInexpensive

May also have beneficial effects on pain,May also have beneficial effects on pain,asthenia and moodasthenia and mood

Causes less fluid retention than otherCauses less fluid retention than other

corticosteriodscorticosteriods


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StimulantStimulant

DexamethasoneDexamethasone

May need to use caution with history ofMay need to use caution with history of

DMDM

Usually not concerned in the EOL settingUsually not concerned in the EOL setting

about long-term complications of steroidsabout long-term complications of steroids

May be a good choice in COPD patientsMay be a good choice in COPD patients

who have become steroid dependentwho have become steroid dependent


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StimulantStimulant

Dronabinol (Marinol)Dronabinol (Marinol) Usually used in young patients with pastUsually used in young patients with past

experience with marijuanaexperience with marijuana

Expensiveup to $500/monthExpensiveup to $500/month

Requires DEA Schedule IIIRequires DEA Schedule III

Usually used in HIV or as part ofUsually used in HIV or as part of

treatment protocol with chemotherapytreatment protocol with chemotherapy

ifi i l i i ifA ifi i l N i i Lif


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Artificial Nutrition at LifesArtificial Nutrition at Lifes

EndEnd

Tube FeedingTube Feeding Tube feeding and forced feeding inTube feeding and forced feeding in

terminally ill patients have not beenterminally ill patients have not been

shown to prolong lifeshown to prolong life

Nasogastric and gastrostomy tubeNasogastric and gastrostomy tube

feedings are associated with:feedings are associated with:

Aspiration pneumoniaAspiration pneumonia Self extubation and thus use ofSelf extubation and thus use of

restraintsrestraints

Nausea and diarrheaNausea and diarrhea


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EndEnd

TPNTPNMeta-analysis of 12 randomizedMeta-analysis of 12 randomized

trialstrials

in cancer patients (1980s)in cancer patients (1980s)

Decreased survivalDecreased survival

Decreased response to chemotherapyDecreased response to chemotherapy

Increased rate of infectionsIncreased rate of infections

Is Anorexia ever a protectiveIs Anorexia ever a protective


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EndEnd

Consider Potential BurdensConsider Potential Burdens

Tube feeding and IV hydration oftenTube feeding and IV hydration often

increase secretions, ascites andincrease secretions, ascites and

effusions, which require additionaleffusions, which require additional

treatmentstreatments

Always ask:Always ask:

Are these kinds of treatmentsAre these kinds of treatments

in line with the Goals of Care?in line with the Goals of Care?


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Asthenia/FatigueAsthenia/Fatigue

The Palliative ResponseThe Palliative Response



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Impact ofImpact of

Asthenia/FatigueAsthenia/Fatigue Reported by >90% of persons at LifesReported by >90% of persons at Lifes

EndEnd

Often most distressing symptomOften most distressing symptom

Even compared to pain or anorexiaEven compared to pain or anorexia

Limits activityLimits activity

Increases dependencyIncreases dependency

-Diminishes sense of control self-


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Prevalence ofPrevalence of

Asthenia/FatigueAsthenia/Fatigue Universal with biologic response modifiersUniversal with biologic response modifiers

>96% with chemotherapy or radiation>96% with chemotherapy or radiation

>90% with persistent or progressive>90% with persistent or progressive

cancerscancers

Common with many other illnesses withCommon with many other illnesses with

end organ failureend organ failure

(Congestive Heart Failure, Chronic Pulmonary(Congestive Heart Failure, Chronic Pulmonary

Disease, Chronic Renal Failure, General Debility)Disease, Chronic Renal Failure, General Debility)


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Characteristics ofCharacteristics of

Asthenia/FatigueAsthenia/Fatigue SubjectiveSubjective

SeveritySeverity

DistressDistressTime LineTime Line

MultidimensionalMultidimensional Weakness and or lack of energyWeakness and or lack of energy

SleepinessSleepiness

Difficulty concentratingDifficulty concentrating


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Patient ExperiencePatient Experience

Physical SymptomsPhysical Symptoms Generalized weaknessGeneralized weakness

Limb heavinessLimb heaviness

Sleep disturbancesSleep disturbances

InsomniaInsomnia HypersomniaHypersomnia

Un-refreshing/non-restorative sleepUn-refreshing/non-restorative sleep


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Cognitive SymptomsCognitive Symptoms

Short-term memory lossShort-term memory loss

Diminished concentrationDiminished concentration

Diminished attentionDiminished attention


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Emotional SymptomsEmotional Symptoms

Marked emotional reactivity toMarked emotional reactivity to

fatiguefatigue

Decreased motivation/interest inDecreased motivation/interest in

usual activitiesusual activities


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PracticalPractical

Difficulty completing daily tasksDifficulty completing daily tasks

Struggle to overcome inactivityStruggle to overcome inactivity

Post-exertional malaise lastingPost-exertional malaise lastingseveral hoursseveral hours


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Differential DiagnosisDifferential Diagnosis

inin Cancer PatientsCancer PatientsPotential Mechanisms of AstheniaPotential Mechanisms of Asthenia

Associated with CancerAssociated with Cancer

Progressive diseaseProgressive disease CytokinesCytokines

Decreased metabolic substratesDecreased metabolic substrates Change in energy metabolismChange in energy metabolismTreatmentsTreatments

Chemotherapy, radiation, surgery and biologicsChemotherapy, radiation, surgery and biologics

Effects are cumulative and can last for monthsEffects are cumulative and can last for months


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Differential DiagnosisDifferential DiagnosisIntercurrent SystemicIntercurrent Systemic

DiseaseDisease

AnemiaAnemia

InfectionsInfections

MalnutritionMalnutrition

Dehydration and electrolyte imbalanceDehydration and electrolyte imbalance


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Differential DiagnosesDifferential Diagnoses

Sleep disordersSleep disorders

De-conditioning and immobilityDe-conditioning and immobility

Central-acting drugsCentral-acting drugs

Chronic pain/other poorly controlledChronic pain/other poorly controlled

symptomssymptoms DepressionDepression

AnxietyAnxiety


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AssessmentAssessment

Do you have fatigue?Do you have fatigue?

How severe is your fatigue? (Use analogHow severe is your fatigue? (Use analogscale)scale)

Does fatigue interfere with activities?Does fatigue interfere with activities?

Are you worried about the fatigue?Are you worried about the fatigue?

Does fatigue impact your quality of life?Does fatigue impact your quality of life?

How?How?


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Goals of CareGoals of Care

Fatigue usually remains a concernFatigue usually remains a concern

throughout stages of illness at Lifesthroughout stages of illness at Lifes

EndEnd(although may respond in part to treatment)(although may respond in part to treatment)

Modify Goals of Care by Stage ofModify Goals of Care by Stage ofIllnessIllness

Prolongation of life or cure of diseaseProlongation of life or cure of disease

Improving functionImproving function

Eff t F tiEffect on Fatigue


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Effect on FatigueEffect on FatigueDisease-ModifyingDisease-Modifying

TherapiesTherapies Some therapies maySome therapies may worsenworsen

fatiguefatigue

Chemotherapy or radiation for cancerChemotherapy or radiation for cancer

Others mayOthers may improveimprove fatiguefatigue

Dialysis for renal failureDialysis for renal failure

ACE for Congestive Heart FailureACE for Congestive Heart Failure

Oxygen for hypoxiaOxygen for hypoxia

Opioids for pain managementOpioids for pain management


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PatientsPatients

Benefits of ErythropoetinBenefits of Erythropoetin

(EPO)(EPO)Placebo Controlled TrialPlacebo Controlled Trial

Subjects randomized to EPOSubjects randomized to EPO

Hemoglobin 8-10g/dlHemoglobin 8-10g/dl

Increased hemoglobinIncreased hemoglobin

Decreased use of transfusionDecreased use of transfusion Increased Quality of LifeIncreased Quality of Life

Effects independent of tumor responseEffects independent of tumor response


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Anemia in CancerAnemia in Cancer

PatientsPatients Burdens of EPOBurdens of EPO

Requires injectionsRequires injections

(EPO 10,000 units subcutaneous 3 times a(EPO 10,000 units subcutaneous 3 times a

week)week)

Expensive and insurance may notExpensive and insurance may notcovercover($400-$500/mo)($400-$500/mo)

Variable EffectivenessVariable Effectiveness

Takes weeks to be effectiveTakes weeks to be effective


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Management ofManagement of

FatigueFatigue Stop all non-essential medicationsStop all non-essential medications

Look for easily correctableLook for easily correctablemetabolic disordersmetabolic disorders (e.g., decreased(e.g., decreasedpotassium or magnesium levels)potassium or magnesium levels)

Hydration and food supplementsHydration and food supplements

may be helpfulmay be helpful (usually try to avoid(usually try to avoidinvasive enteral and parenteral routes)invasive enteral and parenteral routes)


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Management of FatigueManagement of Fatigue

Associated with DepressionAssociated with Depression Symptoms of Major DepressionSymptoms of Major Depression

Depressed moodDepressed mood AnxietyAnxiety IrritabilityIrritability

TreatmentTreatment

(Choice depends on life expectancy)(Choice depends on life expectancy) SSRIsSSRIs CounselingCounseling Psycho-stimulantsPsycho-stimulants

Supportive managementSupportive management


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DexamethasoneDexamethasone May be helpful in late stages of illnessMay be helpful in late stages of illness

Effect may last for 2-3 monthsEffect may last for 2-3 months

A preferred steroid in this settingA preferred steroid in this setting

Less mineral-corticoid effectLess mineral-corticoid effect

Prednisone results in more edemaPrednisone results in more edema

Dexamethasone 4mg po ~ Prednisone 15mgDexamethasone 4mg po ~ Prednisone 15mg

popo


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Use of DecadronUse of Decadron

DosageDosage Dexamethasone 4-8mg q amDexamethasone 4-8mg q am

May increase to 16mg qdMay increase to 16mg qd

(equivalent to Prednisone 60mg)(equivalent to Prednisone 60mg) Usually no advantage to higher dosesUsually no advantage to higher doses Avoid nighttime dosing because ofAvoid nighttime dosing because of

insomniainsomnia Side EffectsSide Effects

Watch for side effects, but usually wellWatch for side effects, but usually well

toleratedtolerated

Lon -term com lications usuall not aLon -term com lications usuall not a


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Management of FatigueManagement of FatigueSleep HygieneSleep Hygiene

Use Trazedone (Use Trazedone (25-100mg q hs)25-100mg q hs) for insomniafor insomnia

instead of benzodiazepineinstead of benzodiazepine

Avoid nappingAvoid napping

Avoid stimulants in the eveningAvoid stimulants in the evening

Avoid alcohol before bedAvoid alcohol before bed

Exercise during the dayExercise during the day(even sitting up in(even sitting up in

chair)chair)


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Education/CounselingEducation/Counseling Goal SettingGoal Setting

Assist patient to set realistic goalsAssist patient to set realistic goals

Energy ConservationEnergy Conservation

Counsel saving energy for mostCounsel saving energy for most

important activitiesimportant activities

Assistance with Activities of Daily LivingAssistance with Activities of Daily Living

Enlist the assistance of family/otherEnlist the assistance of family/other

supportssupports

Home Health Aide and HomemakerHome Health Aide and Homemaker


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ExerciseExercise

Physical Therapy (PT)Physical Therapy (PT)

Evaluate appropriateness of PT toEvaluate appropriateness of PT to

improve quality, and perhaps evenimprove quality, and perhaps evenquantity, of life for patients with betterquantity, of life for patients with better

prognosisprognosis

Up Out of BedUp Out of Bed

Can significantly impact QOL forCan significantly impact QOL for

patients at Lifes Endpatients at Lifes End

Range of motion to maintain flexibilityRange of motion to maintain flexibility


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Asthenia at Lifes EndAsthenia at Lifes End

Fatigue, weakness, and lack of staminaFatigue, weakness, and lack of stamina

cause sufferingcause suffering

in >90% of persons at Lifes Endin >90% of persons at Lifes End


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ConstipationConstipationThe Palliative ResponseThe Palliative Response



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Overview ofOverview of

ConstipationConstipation DefinitionDefinition

The infrequent passage of small hardThe infrequent passage of small hardfecesfeces

Prevalence at Lifes EndPrevalence at Lifes End

Over half of palliative care patientsOver half of palliative care patients

report constipation as a troublingreport constipation as a troublingsymptomsymptom

InterventionIntervention

>80% of patients at Lifes End need>80% of patients at Lifes End need


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Assess Constipation inAssess Constipation in

All Palliative PatientsAll Palliative Patients Bowel HabitsBowel Habits

Frequency and consistencyFrequency and consistency

Previous bowel habitsPrevious bowel habits

Other SymptomsOther Symptoms

Nausea/vomitingNausea/vomiting

Abdominal pain, distention, anorexiaAbdominal pain, distention, anorexia

InterventionsInterventions

What has been tried and what helps?What has been tried and what helps?


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Assess for ImpactionAssess for Impaction

General RuleGeneral Rule Evaluate for constipation andEvaluate for constipation and

impaction after 48 hours with noimpaction after 48 hours with nobowel movementbowel movement

ObstipationObstipation Functional bowel obstruction fromFunctional bowel obstruction from

severe constipation and impactionsevere constipation and impaction


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Asthenia/FatigueAsthenia/Fatigue

As ContributorsAs Contributors Disruption of normal gastrocolicDisruption of normal gastrocolic

reflexreflex Gastrocolic reflex produces urge to defecateGastrocolic reflex produces urge to defecate

usually within an hour of breakfast and lunchusually within an hour of breakfast and lunch Urge will resolve in 10-15 minutes ifUrge will resolve in 10-15 minutes if

suppressedsuppressed Reflex may disappear if suppressed for severalReflex may disappear if suppressed for several

daysdays

Limited activityLimited activity Frequently cannot walk to the bathroomFrequently cannot walk to the bathroom

Limited privacyLimited privacy


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Support Bowel RoutineSupport Bowel Routine

Assist patient with being upAssist patient with being up Hot beverage if known to beHot beverage if known to be

helpfulhelpful Assist patient to toilet when urgeAssist patient to toilet when urge

occursoccurs Assure as much privacy as possibleAssure as much privacy as possible


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Rectal Digital ExamRectal Digital Exam

TumorTumor

ConstipationConstipation ImpactionImpaction Local fissuresLocal fissures

HemorrhoidsHemorrhoids UlcersUlcers


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Abdominal ExamAbdominal Exam

Bladder distentionBladder distention

Urinary retentionUrinary retention

ObstructionObstruction HerniasHernias MassesMasses

TumorTumor Impacted stoolImpacted stool


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Additional EvaluationAdditional Evaluation

Neurological ExamNeurological Exam Impending cord compressionImpending cord compression

Consider Flat Plate and Upright X-Consider Flat Plate and Upright X-RaysRays High impactionHigh impaction

Bowel obstructionBowel obstruction

Gastric outlet obstructionGastric outlet obstruction

Lab EvaluationLab Evaluation HypercalcemiaHypercalcemia

H okalemiaH okalemia


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Medication ReviewMedication Review OpioidsOpioids

Medications with anticholinergic effectsMedications with anticholinergic effects

DiureticsDiuretics

IronIron

Anticonvulsants and anti-hypertensivesAnticonvulsants and anti-hypertensives

Vincristine and platinolsVincristine and platinols

Antacids with calcium and aluminumAntacids with calcium and aluminum

OndanstronOndanstron


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Continuation ofContinuation of

OpioidsOpioids

Treat constipation rather thanTreat constipation rather than

withdrawing opioidswithdrawing opioids

Never stop opioids as response toNever stop opioids as response to

constipation if patient requiresconstipation if patient requires

opioids for relief of pain or otheropioids for relief of pain or otherdistressing symptomsdistressing symptoms


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Differential DiagnosisDifferential DiagnosisConcurrent DiseasesConcurrent Diseases

DiabetesDiabetes

HypothyroidismHypothyroidism HyperparathyroidiHyperparathyroidi

smsm

Hypokalemia andHypokalemia andhypomagnesemiahypomagnesemia

HerniaHernia

DiverticularDiverticulardiseasedisease

Anal fissures andAnal fissures and

stenosisstenosis

HemorrhoidsHemorrhoids


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Environmental FactorsEnvironmental Factors Decreased food intakeDecreased food intake

DehydrationDehydration Weakness and inactivityWeakness and inactivity

ConfusionConfusion

DepressionDepression Structural barriers to bathroom orStructural barriers to bathroom or

toilettoilet


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Laxative TreatmentsLaxative Treatments

SoftenersSofteners

Surfactants like docusate (Colase)Surfactants like docusate (Colase)

OsmoticOsmotic LactuloseLactulose

SorbitolSorbitol

Bulking agentsBulking agents

Metamucil (usually not appropriate at EOL)Metamucil (usually not appropriate at EOL)

Saline laxativeSaline laxative

Magnesium citrates or Milk of MagnesiaMagnesium citrates or Milk of Magnesia

(MOM)(MOM)


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Large Bowel StimulantLarge Bowel Stimulant

Constipation must be managedConstipation must be managed

in the palliative care settingin the palliative care setting

Bisacodyl (Dulcolax) 1-4 tablets aBisacodyl (Dulcolax) 1-4 tablets a

dayday

Senna 2-8 tablets a daySenna 2-8 tablets a day

Can be much more expensive thanCan be much more expensive than

bisacodylbisacodyl


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Algorithm forAlgorithm for

TreatmentTreatment

Rectal Exam Soft Feces

Impaction

Consider Oil Retention Enema

to soften feces

Spontaneous

Defecation

of Impaction

Manual Dis-impaction

Consider Sedation

with Lorazepam

Go to Soft Feces



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TreatmentTreatment

Base Choice of Treatment

at this point on

* Patient Preference

* Urgency for Bowel Movement

Oral Biscodylor

Magnesium Citrate

Enema* Fleets

* Biscodyl Suppository

Rectal Vault Empty

Soft Feces

Al ith fAl ith f


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TreatmentTreatment

Biscodyl 2-4 QD

May add MOM 30 cc QD

Goal

Bowel Movement

at least every48 hours

Address Environmental Factors* Privacy

* Take advantage of Gastrocolec Reflex

* Access to toilet* Assistance with feeding and hydration

* Maximize activity

Rectal Vault Empty

Increased Risk of Impaction

if interval between bowel movements >48 hours

DD


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DyspneaDyspneaThe Palliative ResponseThe Palliative Response


Th E i fTh E i f


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The Experience ofThe Experience of

DyspneaDyspnea

Shortness of breathShortness of breath

BreathlessnessBreathlessness

Smothering feelingSmothering feeling

SuffocationSuffocation

Present at restPresent at rest

Worsened by activityWorsened by activity


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Diagnosing DyspneaDiagnosing Dyspnea

Self-report is the keySelf-report is the keyTo detecting dyspneaTo detecting dyspnea

To appreciating the severity ofTo appreciating the severity ofdyspneadyspnea

Use analog scaleUse analog scale to help peopleto help people

self-report severity of shortness ofself-report severity of shortness ofbreathbreath Now?Now? At the worst?At the worst?

At the best?At the best?


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Diagnosing DyspneaDiagnosing Dyspnea

Prevalence may be greater in patientsPrevalence may be greater in patients

with life-threatening illnesswith life-threatening illness

COPDCOPD

CHFCHF

Lung cancerLung cancer

Blood gas, oxygen saturation andBlood gas, oxygen saturation and

respiratory rate do not substitute forrespiratory rate do not substitute for

patients self assessment and report ofpatients self assessment and report of

dyspneadyspnea

i


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Fix ItFix It VersusVersusTreat ItTreat It

ParadigmParadigm

Look for reversible causesLook for reversible causes

Help patients, families and colleaguesHelp patients, families and colleagues

consider the burden of treatmentconsider the burden of treatment

of the underlying causeof the underlying cause versusversus thethe

benefitbenefit

Fi ItFix It VV T t ItTreat It


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Fix ItFix It VersusVersusTreat ItTreat It

ParadigmParadigm

Treat dyspnea as a symptom whileTreat dyspnea as a symptom whilelooking for a reversible causelooking for a reversible cause

The cause of the dyspnea may take someThe cause of the dyspnea may take sometime to improvetime to improve

Much dyspnea does not have a reversibleMuch dyspnea does not have a reversiblecause, yet patients do not have to suffercause, yet patients do not have to sufferunrelieved dyspnea for the remainder ofunrelieved dyspnea for the remainder oflifelife

P t ti ll R iblP t ti ll R ibl


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Potentially ReversiblePotentially Reversible

Causes of DyspneaCauses of Dyspnea

Pneumonia and bronchitisPneumonia and bronchitis

Pulmonary edemaPulmonary edema

Tumor and pleural effusionsTumor and pleural effusions BronchospasmBronchospasm

Airway obstructionAirway obstruction

COPDCOPD AsthmaAsthma

Thick secretionsThick secretions

P t ti ll R iblP t ti ll R ibl


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Potentially ReversiblePotentially Reversible

Causes of DyspneaCauses of Dyspnea

AnxietyAnxiety

Pulmonary embolismPulmonary embolism

AnemiaAnemia

Metabolic disturbanceMetabolic disturbance

HypoxemiaHypoxemia

Family and practical issuesFamily and practical issues

Environmental problemsEnvironmental problems

B fitB fit B dB d


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BenefitBenefit VersusVersus BurdenBurden

of Treatmentof Treatment

It is always important toIt is always important to considerconsider

causescauses of dyspneaof dyspnea

However, before deciding the extent ofHowever, before deciding the extent of

evaluation beyond history and physical,evaluation beyond history and physical,

begin tobegin to

Weigh BenefitWeigh Benefit versusversus BurdenBurden

of disease-modifying treatmentof disease-modifying treatment

S t tiS t ti


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SymptomaticSymptomaticManagement OxygenManagement Oxygen

Oxygen is a potent symbol of medicalOxygen is a potent symbol of medical

carecare

Try to avoid maskTry to avoid mask

Causes discomfort from sense ofCauses discomfort from sense of

smotheringsmothering Involves unpleasant accumulation ofInvolves unpleasant accumulation of

mucus and moisturemucus and moisture

Interferes withInterferes withcommunication and oralcommunication and oral

S t tiS t ti


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SymptomaticSymptomaticManagement OxygenManagement Oxygen

Use humidifier if use nasal prongUse humidifier if use nasal prong Most people will not tolerate more than 2Most people will not tolerate more than 2

l/ml/m Be guided by patient comfort, not byBe guided by patient comfort, not by

oxygen saturationoxygen saturation Home oxygen is provided byHome oxygen is provided by

concentrator and cannot provide moreconcentrator and cannot provide morethan 5 l/mthan 5 l/m

A fan or air conditioner many provide theA fan or air conditioner many provide thesame level of comfortsame level of comfort

S t tiS mptomatic


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SymptomaticSymptomatic

ManagementManagement OpioidsOpioids

Opioids are the most effective treatmentOpioids are the most effective treatmentfor unrelieved dyspneafor unrelieved dyspnea

Central and peripheral effectsCentral and peripheral effects

Begin with small doses of short-actingBegin with small doses of short-actingopioidsopioids

MS 5mg or Oxycodone 5mg orally q4 hoursMS 5mg or Oxycodone 5mg orally q4 hoursOffer/May RefuseOffer/May Refuse is often a good startingis often a good startingpointpoint

Use analog scale as in pain managementUse analog scale as in pain management

S t tiS mptomatic


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ManagementManagement OpioidsOpioids

Physicians are afraid people will stopPhysicians are afraid people will stop

breathingbreathing

It may reassure wary colleagues of theIt may reassure wary colleagues of the

safety of this approach to ordersafety of this approach to order Give ifGive if

respiratory rate of greater than 20/mrespiratory rate of greater than 20/m,,

since relief of dyspnea may not besince relief of dyspnea may not berelated to decrease in raterelated to decrease in rate



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ManagementManagement Non-Non-

pharmacologicalpharmacological FanFan

Keep environment cool, but avoid chillingKeep environment cool, but avoid chilling

patientpatient Consider cool foodsConsider cool foods

Reposition patient; allow to sit up in bed orReposition patient; allow to sit up in bed or

chairchair

Avoid environmental irritantsAvoid environmental irritants

Avoid claustrophobic settingsAvoid claustrophobic settings

Have a plan for the next episode ofHave a plan for the next episode of

d s nea to ive atient and famil sensed s nea to ive atient and famil sense



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Symptomaticy p

ManagementManagement

AnxiolyticsAnxiolytics Anxiety may be a component forAnxiety may be a component for

patients suffering with dyspneapatients suffering with dyspnea

Lorazepam(Ativan) is safe to combineLorazepam(Ativan) is safe to combinewith opioids for dyspneawith opioids for dyspnea

0.5-1mg prn q2 hours may be helpful0.5-1mg prn q2 hours may be helpful

Some patients may benefit fromSome patients may benefit fromscheduled dosesscheduled doses


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Dyspnea ReviewDyspnea Review

Dyspnea is common in patientsDyspnea is common in patientsreferred to Palliative Carereferred to Palliative Care

Dyspnea is also common in the generalDyspnea is also common in the generalpatient populationpatient population

Dyspnea can be effectively controlledDyspnea can be effectively controlledin most patients whether or notin most patients whether or not

referred to Palliative Carereferred to Palliative Care

Visual analog scale is the best tool forVisual analog scale is the best tool forassessing dyspnea and monitoringassessing dyspnea and monitoring

effectiveness of its treatmenteffectiveness of its treatment

InsomniaInsomnia


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InsomniaInsomnia




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What is Insomnia?What is Insomnia?

ManifestationsManifestations

Non-refreshing sleepNon-refreshing sleep

Difficulty falling asleepDifficulty falling asleep Early morning awakeningEarly morning awakening

Difficulty maintaining sleepDifficulty maintaining sleep

SymptomsSymptoms

Daytime sleepinessDaytime sleepiness

Daytime lack of concentrationDaytime lack of concentration

P l fP l f


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Prevalence ofPrevalence of

InsomniaInsomnia Common in the populationCommon in the population

Increases with age or illnessIncreases with age or illness

Advanced cancerAdvanced cancer

~ 50% of patients report insomnia~ 50% of patients report insomnia

Palliative care patientsPalliative care patients

~75% of patients admitted to a~75% of patients admitted to a

palliative care unit require a hypnoticpalliative care unit require a hypnotic

medicinemedicine


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Cycle of InsomniaCycle of Insomnia

EtiologyEtiology Pain and other symptoms lead toPain and other symptoms lead to

insomniainsomnia

SequelaeSequelae Insomnia exacerbates otherInsomnia exacerbates other

symptomssymptoms

and makes them harder to bearand makes them harder to bear

EffectsEffects Diminishes coping capacityDiminishes coping capacity

Lowers reported QOLLowers reported QOL

iff i l i i


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Treatment Side EffectsTreatment Side Effects

Diarrhea, nausea, instrumentationDiarrhea, nausea, instrumentation

Chemotherapy induced mucositis, painChemotherapy induced mucositis, pain

Poor Sleep EnvironmentPoor Sleep Environment

Uncomfortable bed, lights, noise, odorsUncomfortable bed, lights, noise, odors Awakened for vital signs, blood draws,Awakened for vital signs, blood draws,

etc.etc.

Blood transfusionBlood transfusion


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Mental DisordersMental Disorders Depression, delirium, anxietyDepression, delirium, anxiety

SubstancesSubstances Coffee, tobacco, caffeineCoffee, tobacco, caffeine

Withdrawal from SubstancesWithdrawal from Substances

Alcohol, benzodiazepines, other drugsAlcohol, benzodiazepines, other drugs

MedicationsMedications Steroids, albuterol, theophyline,Steroids, albuterol, theophyline,

stimulantsstimulants


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Primary Sleep DisorderPrimary Sleep Disorder

Sleep apneaSleep apnea

Restless legs syndromeRestless legs syndrome

Physical SymptomsPhysical Symptoms Pain, dyspnea, coughPain, dyspnea, cough

Diarrhea, nausea, pruritisDiarrhea, nausea, pruritis

Assessment ofAssessment of


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Assessment ofAssessment of

InsomniaInsomnia

Do you experience insomnia?Do you experience insomnia?

Chronic problem or new with this illness?Chronic problem or new with this illness?

What do you think makes it hard to sleep?What do you think makes it hard to sleep?

What works and doesnt work to help?What works and doesnt work to help?

Depression or anxiety causing problems?Depression or anxiety causing problems?

Stimulants, like coffee or alcohol, beforeStimulants, like coffee or alcohol, beforesleep?sleep?



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InsomniaInsomnia

Improve control of pain or otherImprove control of pain or other

symptomssymptoms

Identify and treat depressionIdentify and treat depression

Identify and treat deliriumIdentify and treat delirium Common at Lifes EndCommon at Lifes End

May be mistaken for insomniaMay be mistaken for insomnia

Worsened by some insomniaWorsened by some insomnia



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InsomniaInsomnia

Support treatment for knownSupport treatment for known

primary sleep disorderprimary sleep disorder

E.g., CPAP for sleep apneaE.g., CPAP for sleep apnea

Review medicationsReview medications

Stop unneeded medicinesStop unneeded medicines

Administer steroids/stimulants inAdminister steroids/stimulants in

morningmorning

Counsel about caffeine, alcohol,Counsel about caffeine, alcohol,



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gInsomniaInsomnia

Sleeping EnvironmentSleeping Environment Comfortable bed and positionComfortable bed and position

Appropriate lighting and noise levelAppropriate lighting and noise level(some people need white noise)(some people need white noise)

Reduce interruptions such as vitalReduce interruptions such as vital

signs, medicine, blood draws,signs, medicine, blood draws,transfusionstransfusions

Reduce instrumentation andReduce instrumentation and

monitors with alarmsmonitors with alarms



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gInsomniaInsomnia

Sleep HygieneSleep Hygiene Exercise earlier in dayExercise earlier in day

Establish bedtime ritualEstablish bedtime ritual Employ relaxation techniquesEmploy relaxation techniques

Restrict use of bedRestrict use of bed

Bed is for sleepingBed is for sleeping If unable to sleep, get out of bedIf unable to sleep, get out of bed

Medications for SleepMedications for Sleep


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Medications for SleepMedications for SleepTrazedoneTrazedone

Lack of good evidence about mostLack of good evidence about most

effective medication for insomniaeffective medication for insomnia

Trazedone 25-100mg q hsTrazedone 25-100mg q hs

Has become a common regimenHas become a common regimen

Problems with other medicationsProblems with other medications Positive anecdotal experience ofPositive anecdotal experience of

hospice programshospice programs



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Medications for SleepMedications for SleepBenzodiazepine HypnoticBenzodiazepine Hypnotic

Meant for short-term use (2 weeks orMeant for short-term use (2 weeks or

less)less)

Tolerance develops rapidlyTolerance develops rapidly

May contribute to deliriumMay contribute to delirium

Problems of withdrawalProblems of withdrawal Short-acting formswake up in nightShort-acting formswake up in night

Long-acting formsdaytimeLong-acting formsdaytime

grogginessgrogginess



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Medications for SleepMedications for SleepGABA/BZD AgentsGABA/BZD Agents

ExamplesExamples

Zalepion (Sonata)Zalepion (Sonata)

Zolpidem (Ambien)Zolpidem (Ambien)

Comparison with benzodiazepineComparison with benzodiazepine

Act at same siteAct at same site Same problems and precautionsSame problems and precautions

Cost significantly more without clearCost significantly more without clear

benefitbenefit



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Medications for SleepMedications for SleepAntidepressantsAntidepressants

Good choice if someone is depressedGood choice if someone is depressed

TrazedoneTrazedone

Has become antidepressant of choiceHas become antidepressant of choice

Fewer side effectsFewer side effects

Doxipen and ImipramineDoxipen and Imipramine More sedatingMore sedating

Side EffectsSide Effects ConstipationConstipation

Dry mouthDry mouth

OrthostatisOrthostatis



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Medications for SleepMedications for SleepAntihistaminesAntihistamines

Usually not drug of choiceUsually not drug of choice Effect short-termEffect short-term

Numerous interactions with otherNumerous interactions with othermedicationsmedications

May contribute to deliriumMay contribute to delirium

Benadryl is in many over-the-counterBenadryl is in many over-the-countersleep aidssleep aids

Herbal or natural remedies untestedHerbal or natural remedies untested

R i f I iR i f I i


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Review of InsomniaReview of Insomnia

AssessmentAssessment Often multi-factorialOften multi-factorial

Reassess frequentlyReassess frequently

TreatmentTreatment Treat underlying causes if possibleTreat underlying causes if possible

Use hypnotic medications if neededUse hypnotic medications if needed

Goals of CareGoals of Care Restful sleepRestful sleep

Improved QOL and daytime functioningImproved QOL and daytime functioning

anag ng ausea anuVomitingVomiting


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VomitingVomiting




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NauseaNausea

The unpleasant feeling that there is aThe unpleasant feeling that there is a

need to vomitneed to vomit

A source of distress even if vomitingA source of distress even if vomiting

does not occurdoes not occur

Accompanied by tachycardia,Accompanied by tachycardia,increased salivation, pallor andincreased salivation, pallor and

sweatingsweating


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Retching and VomitingRetching and Vomiting

RetchingRetching

Spasmodic contractions of theSpasmodic contractions of the

diaphragm and abdominal musclediaphragm and abdominal muscle

May lead to vomitingMay lead to vomiting

May persist after the stomach hasMay persist after the stomach has

emptiedemptied

VomitingVomiting

Expulsion of the gastric contentExpulsion of the gastric content

throu h the mouththrou h the mouth

h i i


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The Vomiting CenterThe Vomiting Center

Tractus solitarus,reticular formationin the medulla

Parasympatheticmotor efferents Contraction of

pylorsis

Reduction of loweresophogeal sphincter(LES)

Contraction ofstomach

EmesisVomitingCenter

InputInputh i i


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Into the VomitingInto the Vomiting

CenterCenter Fear and Anxiety May cause

anticipatory nausea

Increased Intra-cranial Pressure Metastatic tumor

Primary tumor Intra-cerebralbleed/trauma

Hydrocephalus

Infection


Cerebral CortexGABA//5HT

T


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TreatmentTreatment

Fear and Anxiety

Lorazepam

1mg q6-8hours

Counseling Increased Intra-

cranial Pressure

Dexamethasone

4-10mg q6

Mannitol Infusion

(short term bridgeto definitivetreatment)

Radiation Therapy



uInto the VomitingInto the Vomiting


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CenterCenter Vestibular

Dysfunction(Vertigo)

Causes Inner ear infection Sinus congestion Primary vertigo Hyponatremia

1st Line Treatment Antihistamines

Meclizine

2nd Line Treatment Anticholinergic

Scopolamine

EmesisVomiting

Center


Vestibular Nuclei

InputInputInto the VomitingInto the Vomiting


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CenterCenter ChemoreceptorTriggerZone

Drugs Opioids

Digoxin

Antibiotics

Cytotoxics Anti-

convulsants

Uremia

Hypercalcemia

EmesisVomiting

Center

Cerebral Cortex

GABA//5HT

Vestibular NucleiAchm/H1

Chemo-Receptor

Trigger Zone5HT3/D2

InputInputI h V i iI t th V iti


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CenterCenter Chemoreceptor

Trigger Zone

1st LineTreatment

Dopamineantagonist

Haloperidol

Prochlorperazine

Metoclopramide

2nd LineTreatment

EmesisVomiting

Center

Cerebral Cortex

GABA//5HT


Chemo-Receptor

Trigger Zone5HT3/D2

InputInputInto the VomitingInto the Vomiting


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CenterCenter GI Disorders Constipation

GI obstruction

Gastroparesis Gastritis

(NSAID)

Metastatic

disease Hepatomegal

y

Ascites

EmesisVomiting

Center



Chemo-Receptor

Trigger Zone5HT3/D2

GIVagal/Splanchnic

Afferents

TreatmentTreatment


105/301

TreatmentTreatment

GI DisordersGI Disorders Relieve

constipation Relieve

obstruction Review

medications H2 blockers or

PPI

1st line Metoclopramide

Consider

EmesisVomiting

Center



Chemo-Receptor

Trigger Zone

5HT3/D2

GIVagal/Splanchnic

Afferents

InputInput


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InputInput

Into the Vomiting CenterInto the Vomiting Center

EmesisVomiting

Center



Chemo-ReceptorTrigger Zone

5HT3/D2

GIVagal/Splanchnic

afferents

T t t PlT t t Pl


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Treatment PlanTreatment Plan

Relaxing and non-stressful environmentRelaxing and non-stressful environment

Medication after meals, except for anti-Medication after meals, except for anti-

emeticsemetics

Mouth care and topical anti-fungal prnMouth care and topical anti-fungal prn

Remove sources of offensive odorsRemove sources of offensive odors

Small portions, frequent mealsSmall portions, frequent meals

Monitor for constipation or bladderMonitor for constipation or bladder

T t t PlT t t Pl


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Treatment PlanTreatment Plan

Dexamethasone as a non-specific anti-Dexamethasone as a non-specific anti-inflammatoryinflammatory

Cannabinoids (Marijuana or Marinol)Cannabinoids (Marijuana or Marinol)

Some new atypical anti-depressantsSome new atypical anti-depressants(Rimeron)(Rimeron)

When all else fails, go back to beginningWhen all else fails, go back to beginning

If mechanical obstruction, may benefitIf mechanical obstruction, may benefitfrom octratide (see plan of care for GIfrom octratide (see plan of care for GI

obstruction)obstruction)

Feeding by Mouth at LifesFeeding by Mouth at LifesEndEnd


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EndEnd

A Palliative ResponseA Palliative Response


Th S ttiTh S tti


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The SettingThe Setting

EnvironmentEnvironment - Calm and unhurried- Calm and unhurried

PosturePosture - Upright - Chair is preferable- Upright - Chair is preferable Edge of bed preferable to in bed, butEdge of bed preferable to in bed, but

unstableunstable

Assistance from family or nursingAssistance from family or nursingstaffstaff

Free nursing time by eliminatingFree nursing time by eliminatingactivities unnecessary at Lifes Endactivities unnecessary at Lifes End ((e.g.,e.g.,frequent vital signs)frequent vital signs)

Role of Occupational TherapyRole of Occupational Therapy

Special aidsSpecial aids (sipper cups/wide-grip utensils)(sipper cups/wide-grip utensils)

Asthenia or NeuromuscularAsthenia or Neuromuscular

Di dDi d


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DisordersDisorders

Preparation for EatingPreparation for EatingPosturePosture

Upright positionUpright position

Stabilize the headStabilize the head

MealMeal Small frequent mealsSmall frequent meals

Bite-sized pieces or soft pureed foodBite-sized pieces or soft pureed food

Moisten food with gravy or saucesMoisten food with gravy or sauces

Patients often prefer soft and cool foodsPatients often prefer soft and cool foods

Supplements such as Ensure may beSupplements such as Ensure may be

helpful, especially for elderly who preferhelpful, especially for elderly who prefer

Asthenia or NeuromuscularAsthenia or Neuromuscular

DisordersDisorders


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DisordersDisorders

Safety PrecautionsSafety Precautions

EatingEating

Encourage small sips to clear mouthEncourage small sips to clear mouth

Remind patients to chew thoroughlyRemind patients to chew thoroughly Meal may take 30-45 minutesMeal may take 30-45 minutes

Post-Meal PrecautionPost-Meal Precaution Reduce risk of reflux by encouragingReduce risk of reflux by encouraging

upright position for 15-30 minutesupright position for 15-30 minutes

after eatingafter eating

D tDentures


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DenturesDentures

HygieneHygiene

Assist patient with cleaning and useAssist patient with cleaning and use

Proper FitProper Fit May need adhesiveMay need adhesive May need to be refitted or replacedMay need to be refitted or replaced

Personal PreferencePersonal Preference

Some patients prefer to wear denturesSome patients prefer to wear dentures

Others may choose to stop using themOthers may choose to stop using them

Oral HygieneOral Hygiene


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Oral HygieneOral Hygiene

CleanlinessCleanliness

Encourage and assist with brushing andEncourage and assist with brushing and

flossing 2-3 times dayflossing 2-3 times day

Preventing InfectionPreventing Infection

Antibiotics for periodontal diseaseAntibiotics for periodontal disease

Dental InterventionDental Intervention

Dental work or extraction if indicatedDental work or extraction if indicated

Fluoride treatment as needed in specialFluoride treatment as needed in special

Taste DisordersTaste Disorders


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Taste DisordersTaste Disorders

Treat Underlying DisorderTreat Underlying Disorder

Sinusitis or other infectionsSinusitis or other infections

Gastric refluxGastric reflux Excessive sputumExcessive sputum

Treat Symptom of Bad TasteTreat Symptom of Bad Taste

Supplements, especially zinc, may provideSupplements, especially zinc, may providereliefrelief

Review medications that may taste badReview medications that may taste bad


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Dry MouthDry Mouth


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yy

from Medicationfrom Medication

Seek to avoid side effect of drySeek to avoid side effect of dry

mouthmouth

Substitute drug if possibleSubstitute drug if possible

Trazedone instead of amitriptyline forTrazedone instead of amitriptyline for

insomniainsomnia

Reduce dosage if possibleReduce dosage if possible

Dry MouthDry Mouth


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yy

in Last Hours of Lifein Last Hours of Life

Increase liquids by mouthIncrease liquids by mouth

Ice chipsIce chips PopsiclesPopsicles Flavored icesFlavored ices

Mouth Care may be more effectiveMouth Care may be more effective

and can involve family in careand can involve family in care

Assisted sipsAssisted sips Moistened sponge stickMoistened sponge stick Lip balmLip balm

Anti-fungal creams for celosisAnti-fungal creams for celosis

Oral CandidiasisOral Candidiasis


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(Thrush)(Thrush)

AssessmentAssessment

Always suspect this infection as cause ofAlways suspect this infection as cause of

problems with eatingproblems with eating

TreatmentTreatment

Nystatin Suspension Swish and SwallowNystatin Suspension Swish and Swallow Fluconazole (Diflucan)Fluconazole (Diflucan)

100mg daily for 10-14 days100mg daily for 10-14 days

More expensiveMore expensive

Easier and more quickly effectiveEasier and more quickly effective

Viral Infections andViral Infections and


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Cold SoresCold Sores

EtiologyEtiology

Usually caused by herpetic infectionUsually caused by herpetic infection

TreatmentTreatment

Consider Acylovir (Zovirax)Consider Acylovir (Zovirax) Consider other anti-viral treatmentConsider other anti-viral treatment

in cases of resistance and otherin cases of resistance and other

special factorsspecial factors

Reflux EsophagitisReflux Esophagitis


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Reflux EsophagitisReflux Esophagitis

Practical ConsiderationsPractical Considerations

Small mealsSmall meals

Keep patient upright after mealsKeep patient upright after meals

Medical ManagementMedical Management

May need prokinetic such asMay need prokinetic such asmetoclopromidemetoclopromide

Manage constipationManage constipation H2 blockersH2 blockers

MucositisMucositisO l L ith S dO l L ith S d


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Oral Lavage with SodaOral Lavage with Soda

WaterWaterProcedureProcedure

Baking soda (sodium bicarbonate)Baking soda (sodium bicarbonate)

15 grams to a liter of water15 grams to a liter of water Swish and spitSwish and spit

Keep at bedside for patient to use asKeep at bedside for patient to use as

neededneeded

AdvantageAdvantage

Helps cleanse mouth of dead tissue andHelps cleanse mouth of dead tissue and

debris

MucositisMucositisMagic/MiracleMagic/Miracle


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Magic/MiracleMagic/Miracle

MouthwashMouthwash Consult pharmacy aboutConsult pharmacy about

preparationpreparation

Combination of medicationsCombination of medications May contain diphenhydramine, viscousMay contain diphenhydramine, viscous

xylocaine, Maalox, nystatin, tetracylinexylocaine, Maalox, nystatin, tetracyline

Order bottle to bedside for useOrder bottle to bedside for useby patient as neededby patient as needed

Alternate with soda-wash rinseAlternate with soda-wash rinse

MucositisMucositis


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Viscous XylocaineViscous Xylocaine

DosageDosage

2% 5ml every 4 hours as needed2% 5ml every 4 hours as needed

PreparationPreparation Flavor or dilute to lessen its bad tasteFlavor or dilute to lessen its bad taste

TimingTiming

Sometimes used before mealsSometimes used before meals May make it harder to swallow -May make it harder to swallow -

changes sensation in mouthchanges sensation in mouth

MucositisMucositis


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OverviewOverview

A somatic type of painA somatic type of pain

Opioid TherapyOpioid Therapy

Patients can usually benefit andPatients can usually benefit andrespondrespond

May need to give opioid parentrally inMay need to give opioid parentrally insevere casessevere cases

Indications for Thalidomide 200mgIndications for Thalidomide 200mg

dailydaily

Severe mucosal damageSevere mucosal damage

Review ofReview of


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Difficulty with EatingDifficulty with Eating

PrevalencePrevalence Common in patientsCommon in patients

SufferingSuffering

Causes significant distressCauses significant distress

EtiologyEtiology Often multi-factorialOften multi-factorial

HopeHope In majority of patients, careful andIn majority of patients, careful and

thoughtful evaluation can relievethoughtful evaluation can relieve

suffering improve quality of life increasesuffering improve quality of life increase

HydrationHydration


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Goals of HydrationGoals of Hydration


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Goals of HydrationGoals of Hydration

Help maintain functionHelp maintain function

Improve Quality of Life (QOL)Improve Quality of Life (QOL)

May improve deliriumMay improve delirium Help satisfy subjective sensation ofHelp satisfy subjective sensation of

thirst and hungerthirst and hunger

Engage family and friends in careEngage family and friends in care

Appetite and OralAppetite and OralIntakeIntake


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IntakeIntake

at Lifes Endat Lifes End StatusStatus Declines in most patientsDeclines in most patients

People may take only few sips or bitesPeople may take only few sips or bitesin last days of lifein last days of life

Typical Clinical ResponseTypical Clinical Response Most hospital and nursing homeMost hospital and nursing homepatients have feeding tubes and/orpatients have feeding tubes and/or

IVs at time of deathIVs at time of death

Indications forIndications for


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HydrationHydration

Reversible ProcessReversible Process

(e.g., constipation)(e.g., constipation)

Treatable InfectionTreatable Infection

(e.g., thrush)(e.g., thrush)

Temporary InsultTemporary Insult

Burdens ofBurdens ofEnteral and PerenteralEnteral and Perenteral


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Enteral and PerenteralEnteral and Perenteral

FluidsFluids

Invasive procedureInvasive procedure

Pain and distressPain and distress

Edema and pulmonary congestionEdema and pulmonary congestion

Provides little comfortProvides little comfort

Burden adds to sufferingBurden adds to suffering

Burden often outweighs benefitBurden often outweighs benefit

Diagnostic andDiagnostic andTreatmentTreatment


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TreatmentTreatment

ConsiderationsConsiderationsDiagnosisDiagnosis Signs and symptoms more important thanSigns and symptoms more important than

lab testslab tests

Skin tentingSkin tenting Concentrated urine with decline inConcentrated urine with decline inoutputoutput

Postural symptomsPostural symptoms

Dry mouthDry mouthTreatmentTreatment

Look for reversible causes of declineLook for reversible causes of decline Easier to manage early than lateEasier to manage early than late

Complication ofComplication ofEnteral and PerenteralEnteral and Perenteral


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Enteral and PerenteralEnteral and Perenteral

FluidsFluids Edema (third-spacing of fluids)Edema (third-spacing of fluids)

Indicates intravascular fluid depletionIndicates intravascular fluid depletion

rather than pure dehydrationrather than pure dehydration Often worsened by E/P fluidsOften worsened by E/P fluids

Often worsens pulmonaryOften worsens pulmonary

congestioncongestion

Often leads to dyspnea withoutOften leads to dyspnea without

other benefitsother benefits

Typical Concerns ofTypical Concerns ofPatients andPatients and


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Patients andPatients and

CaregiversCaregivers Dependence on others to be fedDependence on others to be fed

Loss of appetiteLoss of appetite

Weight lossWeight loss

Loss of food as symbol of loveLoss of food as symbol of love

Fostering PatientFostering Patient


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ControlControl

Some persons refuse food or fluidSome persons refuse food or fluidas way of having controlas way of having control


Foster control and good decisions byFoster control and good decisions by

providing accurate informationproviding accurate information Provide patient-directed dietProvide patient-directed diet

Feature foods easily swallowed/digestedFeature foods easily swallowed/digested

DehydrationDehydrationThe PalliativeThe Palliative


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The PalliativeThe Palliative

ResponseResponse Items for dry mouth and sense of thirstItems for dry mouth and sense of thirst Ice chipsIce chips Ice cream, puddingsIce cream, puddings

Frozen popsiclesFrozen popsicles

Drinking aidsDrinking aids Sipper cups, wide gripsSipper cups, wide grips

Thick-it for fluids assists withThick-it for fluids assists withswallowingswallowing

Companionship and assistance atCompanionship and assistance atmealsmeals

Ideas for OralIdeas for Orald i


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HydrationHydration Replete electrolytesReplete electrolytes

Sports drinksSports drinksTomato-based juices for sodiumTomato-based juices for sodium

Hydrate with sipsHydrate with sipsTwo tablespoons of fluid four times inTwo tablespoons of fluid four times in

an hour equals 120ml of fluidan hour equals 120ml of fluid

Encourage families to offer sips withEncourage families to offer sips witheach TV commercialeach TV commercial

An IV at rate of 75cc/hr takes 5 hoursAn IV at rate of 75cc/hr takes 5 hoursto infuse fluids equivalent to a cannedto infuse fluids equivalent to a canneddrink (355ml)drink (355ml)

Oral HydrationOral HydrationB fi R i


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Benefit ReviewBenefit Review

Low technologyLow technology

Minimal riskMinimal risk

Effectively administered at homeEffectively administered at home

Encourages human contactEncourages human contact

Can be pleasurable for patientCan be pleasurable for patient

Less risk of causing fluid overloadLess risk of causing fluid overload

Enteral (NG/PEG) Tube-Enteral (NG/PEG) Tube-FeedingFeeding


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gg

at Lifes Endat Lifes End

No evidence of benefitNo evidence of benefit Causes patient discomfortCauses patient discomfort

Increases use of restraintsIncreases use of restraints

Sometimes goals of care dictate aSometimes goals of care dictate a trialtrial

(e.g., Patient with esophageal cancer and(e.g., Patient with esophageal cancer and

PEG tube undergoing palliative radiationPEG tube undergoing palliative radiation

to resolve esophageal obstruction)to resolve esophageal obstruction)

ASKASK

Is tube-feeding a bridge to resuming oralIs tube-feeding a bridge to resuming oral

Enteral FeedingsEnteral Feedings


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Enteral FeedingsEnteral Feedings

BenefitsBenefits

Increased mentalIncreased mental

alertnessalertness

Reduce familyReduce family

anxietyanxiety

Potentially prolongPotentially prolonglife for special eventlife for special event

BurdensBurdens

Risk of aspirationRisk of aspiration Potential forPotential for

infectionsinfections

Diarrhea andDiarrhea and

distentiondistention NauseaNausea

Invasive proceduresInvasive procedures

RestraintsRestraints

HypodermoclysisHypodermoclysis(Subcutaneous Fluids)(Subcutaneous Fluids)


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(Subcutaneous Fluids)(Subcutaneous Fluids)

(30-50cc/hr of D5 1/2 Normal Saline)(30-50cc/hr of D5 1/2 Normal Saline)

AdvantagesAdvantages Simple technology for home useSimple technology for home use

DisadvantagesDisadvantages Hospitals/nursing homes often notHospitals/nursing homes often not

preparedprepared Needle may still come dislodgedNeedle may still come dislodged Pain and swelling at sitePain and swelling at site Some risk of fluid overloadSome risk of fluid overload May still need restraintsMay still need restraints Cost of treatmentCost of treatment

Perenteral (Intravenous)Perenteral (Intravenous)

FluidsFluids


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DisadvantagesDisadvantages

InvasiveInvasive

Can be difficult and painful to insert IVCan be difficult and painful to insert IV

Risk of infectionsRisk of infections

Use of restraintsUse of restraints

Risk of fluid overloadRisk of fluid overload

Sometimes seen as barrier to home careSometimes seen as barrier to home care

Parenteral IntravenousParenteral Intravenous

FluidsFluids


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FluidsFluids

ConsiderationsConsiderations Goals of CareGoals of Care Is this a bridge resuming oral intake?Is this a bridge resuming oral intake?

Consider time trial (2 liters over 8 hours)Consider time trial (2 liters over 8 hours) Stop IV fluids if not helpfulStop IV fluids if not helpful

Parenteral fluids may blunt thirst andParenteral fluids may blunt thirst and

hungerhunger

Some patients resume oral intake whenSome patients resume oral intake when

fluids discontinuedfluids discontinued

Avoid KVO (Keep Vein Open) fluidsAvoid KVO (Keep Vein Open) fluids

HydrationHydrationThe PalliativeThe Palliative


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The PalliativeThe Palliative

ResponseResponse Try the oral routeTry the oral route Seek reversible cause of decrease oralSeek reversible cause of decrease oral

intakeintake

Balance burden against benefit ofBalance burden against benefit ofperenteral and enteral hydrationperenteral and enteral hydration

Consider Goals of CareConsider Goals of Care

If using a more invasive routeIf using a more invasive route Consider a time trialConsider a time trial Observe carefully to maintain safetyObserve carefully to maintain safety

andand

Intestinal ObstructionIntestinal Obstruction


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DiagnosticDiagnosticid i


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ConsiderationsConsiderations EtiologyEtiology

Ovarian cancer late manifestationOvarian cancer late manifestation

Colorectal cancers late manifestationColorectal cancers late manifestation

Abdominal tumorsAbdominal tumors Pelvic primary tumorsPelvic primary tumors

DistinctionsDistinctions

PartialPartial versusversus completecomplete IntermittentIntermittent versusversus persistentpersistent

SingleSingle versusversus multiple sitesmultiple sites

SmallSmall versusversus large bowellarge bowel



147/301

Managementg

SurgicalSurgical

Best palliative treatment if possibleBest palliative treatment if possible

Not possible in some patientsNot possible in some patients

Non-SurgicalNon-Surgical

Co-morbid illness may makeCo-morbid illness may makepreferablepreferable

Progression of disease may makeProgression of disease may make

preferablepreferable

Good PrognosticGood Prognostic

F t F SF t F S


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Factors For SurgeryFactors For Surgery

Large bowel obstruction treated withLarge bowel obstruction treated with

diverting colostomydiverting colostomy

Single site of obstructionSingle site of obstruction

Absence of ascitesAbsence of ascites

Good preoperative performance statusGood preoperative performance status

Poor PrognosticPoor Prognostic

F t F SFactors For S rger


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Factors For SurgeryFactors For Surgery

Proximal gastric obstruction or SBOProximal gastric obstruction or SBO

AscitesAscites

Multiple sites of obstructionMultiple sites of obstruction Diffuse peritoneal carcinomatosisDiffuse peritoneal carcinomatosis

Previous surgery and radiationPrevious surgery and radiation

treatmenttreatment Poor performance and nutritionalPoor performance and nutritional

statusstatus

Significant distant metastatic diseaseSignificant distant metastatic disease

PlacingPlacing Stents byStents byE dE d


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EndoscopyEndoscopy

Esophageal obstructionEsophageal obstruction

Rectal obstructionRectal obstruction

Less effective in other sitesLess effective in other sites

Sometimes well tolerated but can lead toSometimes well tolerated but can lead to

perforation, obstruction and painperforation, obstruction and pain

Usually only a temporary solutionUsually only a temporary solution

NG or VentingNG or Venting

GastrostomyGastrostomy


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GastrostomyGastrostomy

Most helpful in more proximalMost helpful in more proximalobstructionobstruction

Decompress the stomach but NG tubeDecompress the stomach but NG tubenot tolerated long-termnot tolerated long-term

Venting gastrostomy may be moreVenting gastrostomy may be moreacceptable for longer termacceptable for longer term

Rarely used due to generally poorRarely used due to generally poorcondition of patientscondition of patients

Goals of CareGoals of Care


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Relief of painRelief of pain

Relief of nausea and vomitingRelief of nausea and vomiting

Avoidance of the NG TubeAvoidance of the NG Tube Support of patient and family asSupport of patient and family as

unitunit

Emotionally charged situationEmotionally charged situation Inability to eatInability to eat

Imminent death often within a fewImminent death often within a few

days to no more than few weeksdays to no more than few weeks

Route of MedicationRoute of Medication


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Oral route not reliableOral route not reliable

Alternatives to Oral RouteAlternatives to Oral Route SubcutaneousSubcutaneous SublingualSublingual

TopicalTopical

IntravenousIntravenous

RectalRectal

Pain ManagementPain Management


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gg

Usually use morphineUsually use morphine

Sublingual or subcutaneous routeSublingual or subcutaneous route Titrate dose to comfortTitrate dose to comfort

Usually best to use small, frequentUsually best to use small, frequent

dosing scheduledosing schedule

Pumps with both continuous and PCAPumps with both continuous and PCA

are often best choiceare often best choice

DexamethasoneDexamethasone


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40mg IV QD for 4 days40mg IV QD for 4 days

Consider in most patientsConsider in most patients May result in reduction of edema aroundMay result in reduction of edema around

the site of obstruction and in temporarythe site of obstruction and in temporary

relief of obstructionrelief of obstruction

May enable to resume oral medicationsMay enable to resume oral medications

including dexamethosoneincluding dexamethosone

If not effective, can discontinueIf not effective, can discontinue

OctreotideOctreotide


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0.1-2mg SQ q8hours0.1-2mg SQ q8hours

Puts bowel to rest and stops peristalsisPuts bowel to rest and stops peristalsisagainst site of obstructionagainst site of obstruction

Reduces gastric secretionsReduces gastric secretions

Increases electrolyte and fluid re-Increases electrolyte and fluid re-

absorptionabsorption

Often substantially reduces nauseaOften substantially reduces nausea

and vomitingand vomiting

Anti-Secretory DrugsAnti-Secretory Drugs


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Reduce saliva and secretionsReduce saliva and secretions

Produce up to 2 liters a dayProduce up to 2 liters a day

If obstructed, patient must vomit back upIf obstructed, patient must vomit back up

Scopolamine topicallyScopolamine topically

Glycopyrrolate 0.1-2mg SQ q8hoursGlycopyrrolate 0.1-2mg SQ q8hours

H2 Blockade or Proton-Pump InhibitorsH2 Blockade or Proton-Pump Inhibitors

May reduce gastric acid secretionsMay reduce gastric acid secretions

Anti-EmeticsAnti-Emetics


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Metocholopramide (Reglan)Metocholopramide (Reglan) A pro-kinetic not appropriate if obstructionA pro-kinetic not appropriate if obstruction

completecomplete

May be helpful in partial obstructionMay be helpful in partial obstruction

Time trial stop if colic worsensTime trial stop if colic worsens

Dopamine antagonistDopamine antagonist Haloperidol 1 SQ q6 is less sedatingHaloperidol 1 SQ q6 is less sedating

Chlopromazine 25mg q6 PR is more sedatingChlopromazine 25mg q6 PR is more sedating(less acceptable)(less acceptable)

Lorazepam 1-2mg SQ q6Lorazepam 1-2mg SQ q6

Medical ManagementMedical Management


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ed ca a age eg

OutcomeOutcomeThese regimens relieve symptomsThese regimens relieve symptoms

satisfactorily in most patientssatisfactorily in most patients Patient may still vomit several timesPatient may still vomit several times

a day but usually prefers this to NGa day but usually prefers this to NGtube placementtube placement

Oral IntakeOral Intake Offer ice chips, sherbet or juiceOffer ice chips, sherbet or juice Most patients will moderate oralMost patients will moderate oral

intakeintake

Not necessary or kind to makeNot necessary or kind to make

TPNTPN


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TPNTPN

Usually not recommendedUsually not recommended

May have deleterious effectsMay have deleterious effects

Problems with infectionsProblems with infections

Very select patient population mayVery select patient population may

benefitbenefit

HydrationHydration


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y

Assess BurdenAssess Burden versusversus BenefitBenefit

Appropriate only for selected patientsAppropriate only for selected patients

May be difficult to maintain IV siteMay be difficult to maintain IV site

Problems with fluid overloadProblems with fluid overload

HypodermoclysisHypodermoclysis

Hydration via the subcutaneous routeHydration via the subcutaneous route

May be helpful in selected patientsMay be helpful in selected patients



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g

Selection of TreatmentSelection of Treatment

No comparative studies toNo comparative studies to

determine best treatment indetermine best treatment in

management of obstructionmanagement of obstruction

Assess Benefit and BurdenAssess Benefit and Burden

DailyDaily Adjust MedicationAdjust Medication

Maximize control of symptomsMaximize control of symptoms

Pain and Pain ControlPain and Pain Control



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Discussion ofDiscussion of

Ms BrewsterMs Brewster


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Ms. BrewsterMs. Brewster

Ms. Brewster is takingMs. Brewster is taking

(2) Percocet every 4 hours for bone pain(2) Percocet every 4 hours for bone pain

related to osteoporotic spine fracture andrelated to osteoporotic spine fracture and

collapsecollapse

Equianalgesic DoseEquianalgesic DoseMorphine-MS ContinMorphine-MS Contin


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Morphine-MS ContinMorphine-MS Contin

Ms. Brewster is taking the equivalent ofMs. Brewster is taking the equivalent of

Morphine 90mg in 24 hoursMorphine 90mg in 24 hours

Calculate the equianalgesic dose forCalculate the equianalgesic dose for

A)A) MS ContinMS Contin

Equianalgesic DoseEquianalgesic DoseMorphine-Oral MSMorphine-Oral MS


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Morphine-Oral MSMorphine-Oral MS




B)B) Oral MS immediate releaseOral MS immediate release

Equianalgesic DoseEquianalgesic DoseMorphine-Fentanyl PatchMorphine-Fentanyl Patch


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Morphine-Fentanyl PatchMorphine-Fentanyl Patch




C)C) Fentanyl patch (Duragesic)Fentanyl patch (Duragesic)

Equianalgesic DoseEquianalgesic DoseMorphine-OralMorphine-Oral


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HydromorphoneHydromorphone




D)D) Oral hydromorphoneOral hydromorphone

((DilaudidDilaudid))

Equianalgesic DoseEquianalgesic DoseMorphine-OxycontinMorphine-Oxycontin


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Morphine-OxycontinMorphine Oxycontin




E)E) OxycontinOxycontin

Equianalgesic DoseEquianalgesic Dose

Morphine-PCAMorphine-PCA PumpPump


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Morphine-PCAMorphine-PCAPumpPump




F)F) PCA Morphine pump SQ or IVPCA Morphine pump SQ or IV


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Oxycodone andOxycodone and

AcetaminophenAcetaminophen


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AcetaminophenAcetaminophen

Ms. Brewster is takingMs. Brewster is taking

(2) Percocet every 4 hours for bone pain(2) Percocet every 4 hours for bone pain

related to osteoporotic spine fracture and collapserelated to osteoporotic spine fracture and collapse

Percocet is oxycodone 5mg/APAP 325mgPercocet is oxycodone 5mg/APAP 325mg

This is equal to 4 grams ofThis is equal to 4 grams of

acetaminophenacetaminophenin a 24/hr periodin a 24/hr per

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