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Symptom Control Palliative Care Perspective

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Steroids (dexamethasone) Benzodiazepines (lorazepam) THC (Marinol) Pro ... Steroids. Opioids (morphine) 89% control. Antiemetics (prochlorperazine) 13% control ... – PowerPoint PPT presentation

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Title: Symptom Control Palliative Care Perspective


1
Symptom ControlPalliative Care Perspective
  • Charles F. von Gunten, MD, PhD
  • Northwestern University
  • Chicago

2
Palliative Care
  • The combination of active and compassionate
    therapies intended to relieve the suffering of
    individuals and families with a terminal illness
  • May be combined with therapies aimed at reducing
    or curing the illness, or it may be the total
    focus of care.

3
Model for Palliative Care
Curative/Restorative Therapy
Hospice
Diagnosis
Death
Palliative Care
4
Symptom Management
  • Dyspnea
  • Nausea/Vomiting
  • Bowel Obstruction
  • Terminal Delirium

5
Case of Dyspnea
Mary is a 68 yo woman whose cc is dyspnea. She
has a hx of non-small cell lung cancer, malignant
pleural effusion, and COPD. The most recent
thoracentesis did not improve her dyspnea. She is
divorced for 20 years. She has one son who is
single. She lives alone. She describes herself
as independent and hates the idea of depending on
anyone.
6
Dyspnea
  • The uncomfortable awareness of breathing
  • Patient report

7
Epidemiology
  • 30 of all cancer patients
  • 55 of all patients admitted to US Hospice
  • 70 of lung cancer

8
Sensory Control of Breathing
  • Control centers
  • medulla (respiratory rhythm)
  • cerebral cortex (speech)
  • Sensors
  • Chemoreceptors (PaCO2, PaO2)
  • Mechanoreceptors (muscle, vessels)

9
Management of Breathlessness
  • Oxygen
  • Opioids
  • Anxiolytics
  • Bronchodilators
  • Steroids

10
Oxygen
  • Correct Hypoxemia
  • Associated with health care
  • anxiolytic
  • Dont measure pulse-oximetry
  • Cool air across the face
  • fan, open window

11
Opioids
  • Central and Peripheral
  • precise mechanism is unclear
  • COPD
  • 20 improvement in exercise tolerance and dyspnea
  • 17/20 with relief up to 2 years

Tobin MJ. Archives of Internal Medicine
19901501604-1613
12
Dyspneabaseline
Bruera et al Annals of Internal Medicine
1993119906-907.
13
Dyspnea60 min after morphine
14
Opioids
  • Morphine
  • 5 mg po q4h
  • 50 increase over baseline dose for pain
  • Hydromorphone, oxycodone
  • Nebulized morphine
  • 10-100 mg preservative free in 5 cc
  • no difference from saline placebo

15
Anxiolytics
  • Benzodiazepines
  • lorazepam 0.5-1 mg po q4-6h
  • alprazolam, diazepam, midazolam
  • Complementary Therapies
  • exercises
  • cognitive/behavioral

16
Bronchodilators
  • Overt or occult bronchoconstriction
  • wheezes
  • intercostal indrawing with respiration
  • May provoke cough
  • Requires adequate inspiratory effort

17
Steroids
  • Antiinflammatory
  • Decrease swelling
  • Enhanced well-being
  • Dexamethasone 2-20mg qd in am
  • minimal mineralocorticoid effects
  • long half-life permits once daily dosing

18
Nausea and Vomiting Case
  • Janet is a 54 yo woman complains of nausea and
    vomiting. She has a hx of recurrent
    adenocarcinoma of the colon. She has had
    multiple operations, chemotherapy and radiation.
    She has known disease in the abdomen, but no
    evidence of obstruction.

19
Cortex
Chemotrigger Zone
Vestibular Apparatus
Gastric Lining
20
Neurotransmitters
  • Gastric Lining
  • Serotonin
  • Chemotrigger Zone
  • Dopamine, Serotonin, Histamine, Acholine
  • Vestibular Apparatus
  • Histamine, Acetylcholine
  • Cortex

21
Anti-emetics
  • Serotonin
  • Ondansetron (Zofran)
  • Granisetron (Kytril)
  • Dolasetron

22
Anti-emetics
  • Dopamine
  • Prochlorperazine (Compazine)
  • Thiethylperazine (Torecan)
  • Promethazine (Phenergan)
  • Inapsine (Droperidol)
  • Metoclopramide (Reglan)
  • Haloperidol (Haldol)

23
Anti-emetics
  • Acetylcholine
  • Scopolamine (Transderm Scop)
  • Histamine
  • Diphenhydramine (Benadryl)
  • Meclizine (Antivert)
  • Hydroxyzine (Atarax, Vistaril)

24
Anti-emetics
  • Cortical
  • Steroids (dexamethasone)
  • Benzodiazepines (lorazepam)
  • THC (Marinol)
  • Pro-kinetics
  • metoclopramide (Reglan)
  • cisapride (Propulsid)

25
Nausea and Vomiting Continue
  • On her way to Sweden, n/v return. Abdominal Exam
    shows
  • Absence of bowel sounds
  • Three enterocutaneous fistulas
  • Obstructive Series positive

26
Bowel Obstruction
  • Common
  • 11-42 Ovarian Cancer
  • 5-24 Colorectal Cancer
  • Poor Prognosis if Inoperable
  • 64 days

27
Bowel Obstruction
  • Nasogastric Tube--Intermittent Suction
  • Surgical Evaluation
  • Inoperable
  • Venting Gastrostomy

28
Bowel ObstructionMedical Management
  • Symptoms
  • Intestinal colic 72-76
  • Distension pain 92
  • Nausea/Vomiting 68-100
  • Management
  • Steroids
  • Opioids (morphine) 89 control
  • Antiemetics (prochlorperazine) 13 control
  • Antispasmodics (scopolamine) 67 control

29
Somatostatin
  • 14 amino acid Polypeptide
  • serum half-life 3 minutes
  • Central Action
  • Inhibits release of GH and Thyrotropin
  • Peripheral Action
  • Inhibits glandular secretion
  • Pancreas, GI tract

30
Octreotide (Sandostatin)
  • Polypeptide analog of somatostatin
  • Serum half-life of 2 hours
  • 1992 Clinical Report of 2 cases
  • 1994 Prospective 24 cases
  • 14/24 complete response
  • 4/24 partial response
  • median dose 300 mg/day
  • no side effects

31
Octreotide for Bowel Obstruction
  • Octreotide 10 mg/hr continuous infusion
  • Titrate to complete control of n/v
  • If NG tube in place, clamp when volume diminished
    to 100 cc and remove if no n/v
  • Try convert to intermittent sc
  • Continue until death

32
References
  • Lamberts et al. Octreotide NEJM 1996334246-254
  • Mercadante and Maddaloni. Octreotide in the
    management of inoperable gastrointestinal
    obstruction in terminal cancer patients. J Pain
    and Sympt Manag 19927496-498 (2 cases)
  • Riley and Fallon. Octreotide in terminal
    malignant obstruction of the gastrointestinal
    tract. Eur J Pal Care 1994123-25. (16
    prospective cases)

33
Last Hours--delirium
Mrs. B has been in home hospice program for the
past month. Pain from her metastatic breast
cancer has been well controlled with morphine and
dexamethasone. She has had increasing periods of
sleep, punctuated by periods of lucidity. Today,
the hospice nurse calls to say she has been
asleep for the past 2 days. She is now moaning
rhythmically. Several extra doses of morphine
have been given, she is more restless now.
34
Etiology of Terminal Delirium
  • Multiple etiologies
  • hypoxia,malnutrition, sepsis, metabolic
    imbalance, liver and renal failure, tumour
    burden, medication,
  • occurs over hours to days
  • IRREVERSIBLE

35
Management ofTerminal Delirium
  • goals
  • settle, not reverse
  • muscle relaxation, including reduction of
    moaning, groaning
  • reduction of anxiety (person and family)
  • sedation acceptable

36
Management ofTerminal Delirium
  • stop all but essential meds
  • Benzodiazepines (lorazepam)
  • 1-2 mg sublingual
  • Neuroleptics
  • haloperidol, risperidone
  • chlorpromazine, methotrimeprazine

37
Summary
  • Symptom control is Important part of
    palliation--not only part
  • Attention to detail

38
Goals of Medicine
  • Cure
  • Relief of Suffering
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