Palliative Management Of: Nausea And Vomiting Dyspnea Secretions Delirium Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor,

Palliative Management Of:

• Nausea And Vomiting

• Dyspnea

• Secretions

• Delirium

Mike Harlos MD, CCFP, FCFPMedical Director, WRHA Palliative CareProfessor, University of Manitoba Faculty of Medicine

MECHANISM OF NAUSEA AND VOMITING

• vomiting centre in reticular formation of medulla

• activated by stimuli from:

– Chemoreceptor Trigger Zone (CTZ)• area postrema, floor of the fourth ventricle• outside blood-brain barrier (fenestrated venules)

– Upper GI tract & pharynx

– Vestibular apparatus

– Higher cortical centres

Cortex

CTZ

Vestibular

GI

VOMITING CENTRE

Chemoreceptor Trigger Zone

Vestibular Cortical Peripheral

drugs• opioids• chemoTx• etc...

biochemical• Ca++

• renal failure• liver failure

sepsis

radiotherapy

tumor

opioids

anxiety

association

ICP

radiotherapy

chemotherapy

GI irritation• inflammation• obstruction• paresis• compression

Stimuli Of Vomiting Pathways

PRINCIPLES OF TREATING NAUSEA & VOMITING

• Treat the cause, if possible and appropriate

• Environmental measures

• Antiemetic use:

– anticipate need if possible

– use adequate, regular doses

– aim at presumed receptor involved

– combinations if necessary

– anticipate need for alternate routes

Stimulus Area Receptors

Drugs,

MetabolicChemoreceptor

trigger zone

Motion,

PositionVestibular

Visceral Organs

? Non-specific

CNS

↑ ICP Cerebral cortex

D2 5HT

MM HH11

VOMITING CENTRE

EffectorOrgans

Dopamine Serotonin Histamine Muscarinic

CB1

Cannabinoid

CB1

D2

D2

5HT

5HT

HH115HT

HH11

HH11

MM

MM

From:

Arch. Dis. Child. 2004;89;877-880E S Antonarakis and R D W Hain

Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice

Dyspnea

In

Palliative Care

DYSPNEA:

An uncomfortable awareness of breathing

DYSPNEA:

“...the most common severe symptom in the last days of life”

Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 - 98

Approach To The Dyspneic Palliative Patient

Two basic intervention types:

1. Non-specific, symptom-oriented

2. Disease-specific

Simple Non-Specific Measures In Managing Dyspnea

• calm reassurance

• patient sitting up / semi-reclined

• open window

• fan

Non-Specific Pharmacologic Interventions In Dyspnea

• Oxygen - hypoxic and ? non-hypoxic

• Opioids - complex variety of central effects

• Chlorpromazine or Methotrimeprazine - some evidence in adult literature; caution in children due to potential for dystonic reactions

• Benzodiazepines - literature inconsistent but clinical experience extensive and supportive

• Anti-tumor: chemo/radTx, hormone, laser

• Infection

• Anemia

• CHF

• SVCO

• Pleural effusion

• Pulmonary embolism

• Airway obstruction

TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE

DISEASE-SPECIFIC MEDICATIONSFOR DYSPNEA

• Corticosteroids– obstruction: SVCO, airway – lymphangitic carcinomatosis– radiation pneumonitis

• Furosemide– CHF– lymphangitic carcinomatosis

• Antibiotics

• Anticoagulation – pulm. embolus

• Bronchodilators

• Transfusion

Opioids in Dyspnea

Uncertain mechanism

Comfort achieved before resp compromise; rate often unchanged

Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration

Dosage should be titrated empirically; may easily reach doses commonly seen in adults

May need rapid dose escalation in order to keep up with rapidly progressing distress

A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS

How do you know that the

aggressive use of opioids for pain or

dyspnea doesn't actually bring about

or speed up the patient's death?

0

10

20

30

40

50

60

70

80

90

100

Dyspnea Pain Resp. Rate (breaths/min)

O2 Sat (%) pCO2

Pre-Morphine

Post-Morphine

SUBCUTANEOUS MORPHINE INTERMINAL CANCER

Bruera et al. J Pain Symptom Manage. 1990; 5:341-344

Typically, with excessive opioid dosing one would see:

• pinpoint pupils

• gradual slowing of the respiratory rate

• breathing is deep (though may be shallow) and regular

COMMON BREATHING PATTERNS IN THE FINAL HOURS

Cheyne-Stokes

Rapid, shallow

“Agonal” / Ataxic

Palliative Management

of Secretions

0

5

10

15

20

25

30

35

40

45

Study Entrance Last Month

Any

Major Problem

Secretions - Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum Survey

Goldman A et al; Pediatrics 2006; 117; 1179-1186

Managing Secretions in Palliative Patients

Factors influencing approach management: Oral secretions vs.. lower respiratory Level of alertness and expectations thereof Proximity of expected death

“Death Rattle” – up to 50% in final hours of life

At times the issue is more one of creating an environment less upsetting to visiting family/friends

Suctioning: “If you can see it, you can suction it”

Suctioning

Increased Secretions

Mucosal Trauma

CONGESTION IN THE FINAL HOURS“Death Rattle”

• Positioning

• ANTISECRETORY: Scopolamine, glycopyrrolate

• Consider suctioning if secretions are: distressing, proximal, accessible not responding to antisecretory agents

Atropine Eye DropsFor Palliative Management Of Secretions

• Atropine 1% ophthalmic preparation

• Local oral effect for excessive salivation/drooling

• Dose is usually 1 – 2 drops SL or buccal q6h prn

• There may be systemic absorption… watch for tachycardia, flushing

Delirium in

Palliative Care

Definition

Etiologically non-specific global cerebral

dysfunction associated with changes in LOC,

attention, thinking, perception, memory,

psychomotor behavior, emotion and the

sleep/wake cycle

DSM-IV Criteria

A. Change in consciousness with reduced ability to focus, sustain or shift attention

B. Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia

C. Abrupt onset (hours to days) with fluctuation

D. Evidence of medical condition judged to be etiologically related to disturbance

Characteristics

Abrupt onset

Disorientation, fluctuation of symptoms

Hypoactive vs.. hyperactive (restlessness, agitation, aggression) vs. mixed

Changes in sleeping patterns

Incoherent, rambling speech

Fluctuating emotions

Activity that is disorganized and without purpose

Delirium Types

Hypoactive

– confusion, somnolence, alertness

Hyperactive

– agitation, hallucinations, aggression

Mixed (>60%)

– features of both

20% - 44% on admission to a palliative care unit (common reason for admission)

28% - 45% of patients developed delirium while on the palliative care unit

68% - 90% prior to death

Lawlor et al (J Pall Care 1998)– n = 103 pts– 50% of episodes reversible– Terminal delirium in 88%– Hyperactive (5%) vs. hypoactive (47%)– Mixed (48%) most common

Prevalence of Delirium

Delirium versus Dementia

Delirium Dementia

Abrupt onset Insidious onset

Decreased/Fluctuating LOC LOC intact, alert

Erratic behaviour Consistent behaviour

Sleep/wake cycle change Minimal changes

Reversible (theoretically) Irreversible

Causes Of Delirium In Palliative Care

1. Tumour• Primary, metastatic, leptomeningeal, paraneoplastic syndrome

2. Metabolic / physiologic• hypercalcemia• Hyponatremia (hypernatremia less commonly)• ↑ or ↓ glucose• anemia, hypoxia• CO2

• Renal or liver failure

3. Infection – UTI, pneumonia, biliary tract, wounds

4. Medication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretory

5. Medication / Drug withdrawal

6. Etc…..

Management Of Delirium In Palliative Care

1. Environmental Quite, private setting: single room if possible Low lighting, calendar, clock, familiar objects Minimal room changes with unnecessary distractions

2. Fix the Fixable – if possible and appropriate

3. Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible

4. Effective sedation – with frank discussion of anticipated course If delirium irreversible, goal of care is sedation Sedation does not hasten the dying process Will facilitate meaningful visiting Encourage communication, even though patient not interactive