To prevent and relieve suffering, and promote quality of life at every stage of life

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To prevent and relieve suffering, and promote
quality of life at every stage of life
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Common Symptoms
Frank D. Ferris, MDMedical Director, Palliative
Care Standards CENTER FOR PALLIATIVE STUDIES San
Diego Hospice and Palliative Care Education and
Research in the Art and Science of Palliative
Care Department of Family and Preventative
Medicine, UCSD School of Medicine Department of
Family and Community Medicine, andJoint Center
for Bioethics, University of Toronto
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Objectives

• Know general guidelines for managing non-pain
  symptoms
• Know how to assess and manage common symptoms
• www.CPSOnline.info
• Publications / presentations

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General guidelines . . .

• History, physical examination
• Conceptualize likely causes
• Discuss treatment options
• Assist with decision making

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. . . General guidelines

• Provide education, support
• Involve entire interdisciplinary team
• Reassess frequently

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HIV Wasting
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HIV Wasting

• Loss of weight gt 10 of baseline with fever,
  weakness, diarrhea gt 30 days
• inadequate nutrient intake
• excessive nutrient loss
• metabolic dysregulation

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Managementof anorexia / cachexia . . .

• Assess, manage comorbid conditions
• Educate, support
• Favorite foods / nutritional supplements

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. . . Managementof anorexia / cachexia

• Alcohol
• Megestrol acetate
• Dexamethasone
• Dronabinol
• Androgens, eg, testosterone

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Fatigue /Weakness
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Managementof fatigue / weakness . . .

• Promote energy conservation
• Evaluate medications
• Optimize fluid, electrolyte intake
• Permission to rest
• Clarify role of underlying illness
• Educate, support patient, family
• Include other disciplines

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. . . Managementof fatigue / weakness

• Dexamethasone
• feeling of well-being, increased energy
• effect may wane after 4-6 weeks
• continue until death
• Methylphenidate

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Fever /Sweats
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Management of fever / sweats

• Paracetamol (acetaminophen)
• NSAIDs, eg, ibuprofen
• Corticosteroids, eg, dexamethasone
• Anticholinergics, eg, scopolamine
• Rehydration
• Bathing, drying

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Nausea /Vomiting
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Nausea / vomiting

• Nausea
• subjective sensation
• stimulation
• gastrointestinal lining, CTZ, vestibular
  apparatus, cerebral cortex
• Vomiting
• neuromuscular reflex

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Causesof nausea / vomiting

• Metastases
• Meningeal irritation
• Movement
• Mental anxiety
• Medications
• Mucosal irritation

• Mechanical obstruction
• Motility
• Metabolic
• Microbes
• Myocardial

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Pathophysiologyof nausea / vomiting
ChemoreceptorTrigger Zone (CTZ)
Cortex
Vestibular apparatus
Vomiting center

• Neurotransmitters
• Acetylcholine
• Dopamine
• Histamine
• Serotonin

GI tract
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Managementof nausea / vomiting

• Dopamine antagonists
• Antihistamines
• Anticholinergics
• Serotonin antagonists

• Prokinetic agents
• Antacids
• Cytoprotective agents
• Other medications

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Acetylcholine antagonists(anticholinergics)

• Scopolamine
• Atropine

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Dopamine antagonists

• Haloperidol
• Prochlorperazine
• Metoclopramide (also prokinetic)

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Histamine antagonists (antihistamines)

• Diphenhydramine
• Meclizine
• Hydroxyzine

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Serotonin antagonists

• Ondansetron
• Granisetron

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Antacids

• Antacids
• H2 receptor antagonists
• cimetidine
• ranitidine
• Proton pump inhibitors
• omeprazole

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Cytoprotective agents

• Misoprostol
• Proton pump inhibitors
• omeprazole

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Other medications

• Dexamethasone
• Tetrahydrocannabinol
• Lorazepam
• Octreotide

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Constipation
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Constipation

• Medications
• opioids
• calcium-channel blockers
• anticholinergic
• Decreased motility
• Ileus
• Mechanical obstruction

• Metabolic abnormalities
• Spinal cord compression
• Dehydration
• Autonomic dysfunction
• Malignancy

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Managementof constipation

• General measures
• establish normal bowel pattern
• regular toileting
• gastrocolic reflex

• Specific measures
• stimulants
• osmotics
• detergents
• lubricants
• large volume enemas

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Stimulant laxatives

• Prune juice
• Senna
• Casanthranol
• Bisacodyl

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Osmotic laxatives

• Milk of magnesia (other Mg salts)
• Lactulose
• Polyethylene glycol
• Sorbitol
• Magnesium citrate

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Surfactant laxatives(stool softeners)

• Sodium docusate
• Calcium docusate
• Phosphosoda enema prn

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Prokinetic agents

• Metoclopramide

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Lubricant stimulants

• Glycerin suppositories
• Oils
• mineral
• peanut

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Large-volume enemas

• Warm water
• Soap suds

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Constipationfrom opioids . . .

• Occurs with all opioids
• Pharmacologic tolerance developed slowly, or not
  at all
• Dietary interventions alone usually not
  sufficient
• Avoid bulk-forming agents in debilitated patients

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. . . Constipationfrom opioids

• Combination stimulant / softeners are useful
  first-line medications
• casanthranol docusate sodium
• senna docusate sodium
• Prokinetic agents

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Diarrhea
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Causes of diarrhea

• Infections
• GI bleeding
• Malabsorption, eg, lactose intolerance
• Medications, eg, HAART
• Obstruction, eg, cancer
• Overflow incontinence
• Stress

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Management of diarrhea

• Establish normal bowel pattern
• Treat underlying cause
• Avoid gas-forming foods
• Increase bulk, i.e., fiber
• Transient, mild diarrhea
• bismuth salts

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Managementof persistent diarrhea

• Rehydration
• Oral salt containing fluids
• Parenteral
• Loperamide
• Diphenoxylate / atropine
• Tincture of opium
• Octreotide

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Shortnessof Breath(Dyspnea)
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Breathlessness (dyspnea) . . .

• Described as
• shortness of breath
• a smothering feeling
• inability to get enough air
• suffocation

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. . . Breathlessness (dyspnea)

• Only reliable measure is patient self-report
• Respiratory rate, pO2, blood gas determinations
  DO NOT correlate with the feeling of
  breathlessness
• Prevalence 12 74

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Causes of breathlessness

• Anemia
• Anxiety
• Airway obstruction
• Bronchospasm
• Hypoxemia
• Infections
• Metabolic

• Pleural effusion
• Pulmonary edema
• Pulmonary embolism
• Thick secretions
• Family / financial / legal / spiritual /
  practical issues

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Managementof breathlessness . . .

• Treat the underlying cause
• antibiotics
• avoid fluid overload
• dry secretions
• Mechanical ventilation

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. . . Managementof breathlessness

• Symptomatic management
• oxygen
• opioids
• anxiolytics
• nonpharmacologic interventions

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Oxygen

• Pulse oximetry not helpful
• Potent symbol of medical care
• Expensive
• Fan may do just as well

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Opioids

• Small doses
• Central and peripheral action
• Relief not related to respiratory rate
• No ethical or professional barriers
• Do not shorten life

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Anxiolytics

• Safe in combination with opioids
• lorazepam
• 0.5-2 mg po q 1 h prn until settled
• then dose routinely q 46 h to keep settled

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Nonpharmacologic interventions . . .

• Reassure, work to manage anxiety
• Behavioral approaches, eg, relaxation,
  distraction, hypnosis
• Limit the number of people in the room
• Open window

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Nonpharmacologic interventions . . .

• Eliminate environmental irritants
• Keep line of sight clear to outside
• Reduce the room temperature
• Avoid chilling the patient

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. . . Nonpharmacologic interventions

• Introduce humidity
• Reposition
• elevate the head of the bed
• move patient to one side or other
• Educate, support the family

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• Common Symptoms
• Summary

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