Management of Common Symptoms in Terminally Ill Patients

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Management of Common Symptoms in Terminally Ill
Patients

• Junior Rotation in Hospice and Palliative Care

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Symptom Prevalence(Cancer, AIDS, many other
terminal conditions)

1. Fatigue
2. Anorexia
3. Pain
4. Nausea
5. Constipation
6. Altered mental states (delirium)
7. Dyspnea

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General Approach to Symptom Management at
End-of-Life

• Search for cause of symptom
• History, physical, laboratory (as appropriate)
• Treat underlying cause (if reasonable)
• Treat the symptom
• Re-evaluate frequently

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Fatigue
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Fatigue

• Most common symptom in medicine
• Lack of energy, tiredness
• Subjective weakness
• Diminished mental capacity
• Not relieved by rest
• May be incapacitating

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Diagnosis of Fatigue

• Often under diagnosed or ignored
• Multidimensional assessment tools available
• The Brief Fatigue Inventory (BFI)http//prg.mdand
  erson.org/bfi.pdf

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Pathogenesis of Fatigue

• Physical causes
• Decreased O2 carrying capacity
• Anemia or CHF
• Cancer, chronic illnesses
• Treatments for cancer, HBP, other
• Psychological causes
• Anxiety and / or depression

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Erythropoietin and Fatigue in Terminal Illness

• May benefit selected patients
• Symptomatic anemia
• Low erythropoietin levels
• Considerations
• Cost
• Time to effect (4 to 6 weeks)

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Palliative treatment of Fatigue

• Nonpharmacologic therapy
• Patient/family education Permission to be tired
• Energy conservation strategies
• Pharmacologic therapy
• Dexamethasone 2-20 mg qAM
• Methylphenidate 2.5-5 mg qAM and noon
• Antidepressant trial (SSRI)

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Anorexia and Cachexia
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Anorexia and Cachexia in the end-of-life setting

• Wasting syndromes
• Anorexia, weight loss, fatigue
• Cancer, chronic organ failure, chronic
  infections, AIDS.
• Treatable causes
• Chronic pain
• Mouth conditions (dryness, mucositis, thrush,
  HSV)
• GI motility problems (e.g., constipation)
• Reflux esophagitis
• Treatments for cancer

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Management of Anorexia and Cachexia, contd

• Hyperalimentation in cancer anorexia / cachexia
  syndromes
• Increase in body fat, not protein
• Potential for harm fluid overload, infections,
  aspiration
• Invasive
• Weigh benefit vs. burden

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Comfort Care for Terminally Ill Patients The
Appropriate Use of Nutrition and Hydration.RM
McCann, WJ Hall, A Groth-Juncker. JAMA 1994 272
1263-6.

• Patients generally did not experience hunger.
  Those who did needed only small amounts of food
  for alleviation.
• Thirst and dry mouth were relieved by mouth care
  and sips of liquid far less than needed to
  prevent dehydration.
• Food and fluid administration beyond the specific
  requests of patients may play a minimal role in
  providing comfort to terminally ill patients.

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Management of Anorexia and Cachexia

• Nonpharmacological therapy
• Patient and family education
• ineffectiveness and discomfort of forced
  feeding/nutrition/hydration
• Replace caregiver need to feed with behaviors
  that alleviate symptoms
• Eliminate dietary restrictions eat p.r.n., in
  amount desired
• Reduce portion size, more frequent meals

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Management of Anorexia and Cachexia

• Pharmacologic therapy
• Dexamethasone 2 to 20 mg po qAM.
• Megesterol (Megace), 200 mg po q6-8 hrs, titrated
  to achieve desired effect.
• Dronabinol (Marinol) 2.5 mg po BID or TID
  titrate dose to patient tolerance and desired
  effect.
• Androgens currently under investigation.

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Nausea and Vomiting
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Nausea and Vomiting

• Frequency in terminal cancer
• Nausea--50 to 60 of patients
• Vomiting--30 of patients
• Can be controlled in 90 of cases

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Nausea and Vomiting key organs involved

• Brain
• Chemoreceptor trigger zone (CTZ)
• Cerebral cortex
• Vestibular apparatus
• Vomiting center
• Gastrointestinal tract

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Nausea and Vomiting neurotransmitters involved

• Serotonin
• Dopamine
• Acetylcholine
• Histamine

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Pathophysiology Nausea and Vomiting
Organ/component Neurotransmitter
Chemoreceptor trigger zone (CTZ) Serotonin, Dopamine, Acetylcholine, Histamine
Cerebral Cortex Complex Learned responses
Vestibular apparatus Acetylcholine, Histamine (H1)
GI Tract Serotonin, Dopamine, Acetylcholine, Histamine (H2)
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Nausea and VomitingSome treatable causes

• Chemoreceptor Trigger Zone
• Drugs
• Metabolic e.g., renal, liver, electrolyte
  hyponatremia, hypercalcemia
• Cortical
• Anticipatory nausea
• Learned responses
• Anxiety, uncontrolled pain

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Nausea and VomitingMore treatable causes

• Vestibular
• Opioids trigger Ach-mediated nausea in vestibular
  apparatus
• Gastrointestinal Tract
• Gastritis/esophagitis
• Constipation, impaction
• Obstruction
• Drugs
• Tube feedings

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Management of Nausea and Vomiting
Class Medication
Dopamine antagonists Haloperidol (Haldol)Prochlorperazine (Compazine)
Histamine H1 receptor blockers Diphenhydramine (Benadryl)Meclazine (Antivert)Hydroxazine (Atarax, Vistaril)Promethazine (Phenergan)
Acetylcholine antagonist Scopolamine (transdermal)
Serotonin antagonists Ondansetron (Zofran)Granisitron (Kytril)Dolasetron (Anzemet)
Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Management of Nausea and Vomiting
Class Medication
Prokinetic agent Metoclopramide (Reglan)
Antacids Liquid Histamine H2 receptor blockers Proton Pump Inhibitors VariousCimetidine, Ranitidine, FamotidineOmeprazole, Lansoprazole
Other useful agents Dexamethasone (Decadron)Dronabinol (Marinol)Lorazepam (Ativan)Octreotide (Sandostatin)
Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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M-Esis the 11 Ms

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

• Mechanical obstruction
• Motility
• Metabolic
• Microbes
• Myocardial

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Management of Nausea and Vomiting
Etiology Pathophysiology Treatment
Metastases cerebral liver Increased ICP direct effect on CTZToxin buildup-gt CTZ Steroids, dopamine, histamine antag.Dopamine, histamine antag.
Mentation Cerebral cortex Anxiolytics (e.g., benzo- diazepines)
Medications Opioids Cancer Chemotherapy CTZ, vestibular, GI tractCTZ, GI tract Dopamine, histamine, acetylcholine antag., prokinetic agent, stimu- lant laxativesSerotonin, dopamine antagonists, cortico- steroids
Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Persistent nausea...in a terminally ill patient

• Start with
• Haloperidol 1 mg PO or SC bid or tid, increase to
  10 to 15 mg/day, as needed
• If needed, add
• Antihistamine (e.g., hydroxyzine) and /or
• Metoclopramide (beware in bowel obstruction)
• Other Ondansetron (Zofran), Granisitron
  (Kytril), methotrimeprazine (Levoprome)

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Constipation, Bowel Obstruction
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Factors Affecting Bowel Movement

1. Intestinal solids
2. Stool water content
3. Gastrointestinal motility
4. Gastrointestinal lubrication

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Constipation What makes us go
Factor Etiologic agent Treatment
Low intestinal solids Low fiber diet Psyllium (caution)
Low stool water content Dehydration, slow stool transit time, reduced secretion Hyperosmolar, nonabsorbable agents, Mg, PO4 saltsGlycerinSorbitol, Lactulose
Low GI motility Bed ridden drugs, neurological Stimulant laxatives senna, bisacodyl, prune juice, cascara
Poor GI lubrication Dehydration Docusate, mineral oil enemas, glycerin suppositories
Adapted with permission from Fast Facts and
Concepts 15, EPERC Resource Center.
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Constipating Drugs

• Morphine
• Tricyclic antidepressants
• Scopolamine
• Diphenhydramine
• Vincristine

• Verapamil
• Other Ca channel blockers
• Iron
• Aluminum
• Calcium salts

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Bowel Obstruction...in advanced cancer

• Incidence 3 overall in Hospice
• Ovarian Cancer 5 to 42
• Colorectal Cancer 10 to 30
• Mechanism mechanical, paralytic
• Symptoms...
• Surgery...limited usefulness in terminally ill
  cancer patients

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Management of Bowel Obstruction in Terminally
Ill Patients

• Surgery extremely poor risk
• Aggressive pain management
• Stool softeners, soft / liquid diet
• Manage nausea (Haldol, Benadryl)
• Octreotide

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Octreotide (SandostatinTM)

• Synthetic analogue of Somatostatin
• Decreases intestinal secretion, bile flow
• Increases intestinal absorption
• Adverse effects
• Dry mouth, Flatulence
• Hypo- or hyperglycemia
• Pain at injection site...
• Dosage and administration
• 150 mg SC, bid OR
• 300 mg over 24h by SC infusion. Max. 600 mg/day

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Delirium
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Delirium and terminal agitation

• Delirium up to 85 of terminal cancer patients
• Features may include
• Clouding of consciousness, altered attention
• Perceptual disturbances
• Acute onset, fluctuating course distinguish
  from dementia

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Delirium--Causes

• D Drugs, especially psychotropics
• E Electrolyte imbalance
• L Liver failure
• I Ischemia or hypoxia
• R Renal failure
• I Impaction of stool
• U Urinary tract or other infection
• M Metastases, other neurological

Adapted from Storey, Primer of Palliative Care,
AAHPM.
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Drug Treatment of Delirium

• Haloperidol 1-2 mg PO or SC q1h to calm the
  crisis, then q6-12 hr
• If more sedation is desired, or for the AIDS
  dementia complex, use
• Thioridazine (Mellaril) 25-50 mg PO q1h until
  calm then q6-12 hr OR
• Chlorpromazine 25-50 mg PO or IV until calm then
  q6-12 hr

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Severe Agitated Delirium

• Consider ADDING
• Chlorpromazine (Thorazine) 100 mg q1h PO, PR or
  IV until calm
• Midazolam (Versed) 0.4-4 mg/hr continuous SC or
  IV infusion
• Lorazepam (Ativan) 1-2 mg q1hr until calm (PO, SL
  or IV)

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Dyspnea
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Breathlessness (dyspnea) . . .

• May be described as
• shortness of breath
• a smothering feeling
• inability to get enough air
• suffocation

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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. . . Breathlessness (dyspnea)

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

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Causes of breathlessness

• Anxiety
• Airway obstruction
• Bronchospasm
• Hypoxemia
• Pleural effusion
• Pneumonia
• Pulmonary edema

• Pulmonary embolism
• Thick secretions
• Anemia
• Metabolic
• Family / financial / legal / spiritual /
  practical issues

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Managementof breathlessness

• Treat the underlying cause
• Symptomatic management
• oxygen
• opioids
• anxiolytics
• nonpharmacologic interventions

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Oxygen

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

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Opioids

• Small doses titrate to get desired relief of
  symptom without side effects
• Relief not related to respiratory rate
• Central and peripheral action

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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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

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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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

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Nonpharmacologic interventions . . .

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

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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. . . Nonpharmacologic interventions

• Introduce humidity
• Reposition
• elevate the head of the bed
• Sit with arms up on pillow on a table
• Educate, support the family

Adapted with permission from the EPEC Project,
Robert Wood Johnson Foundation.
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Resources

• End-of-life Physicians Education Resource Center
  http//www.eperc.mcw.edu
• Education for Physicians on End-of-life Care
  http//www.epec.net