Objectives Objectives Have a better understanding of how physical and mental factors affect symptomatology Be able to use this understanding in the treatment of patients suffering from nausea/vomiting and dyspnea Incorporate skills and knowledge gained into your practice and teaching By the end of this module you will
Objectives. By the end of this module you will. Have a better understanding of how physical and mental factors affect symptomatology Be able to use this understanding in the treatment of patients suffering from nausea/vomiting and dyspnea - PowerPoint PPT Presentation
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ObjectivesObjectives
Have a better understanding of how physical and mental factors affect symptomatology
Be able to use this understanding in the treatment of patients suffering from nausea/vomiting and dyspnea
Incorporate skills and knowledge gained into your practice and teaching
James Hallenbeck, MDAssistant Professor of Medicine,
Stanford School of MedicineDirector, Palliative Care Services, VA Palo Alto
HCS
Definition of a SymptomDefinition of a Symptom“A physical or mental phenomenon, circumstance or change of condition arising from accompanying a disorder and constituting evidence for it… specifically a subjective indicator perceptible to the patient and as opposed to an objective one (compare with sign).”
The New Shorter Oxford English Dictionary, cited by The Oxford Textbook of Palliative Medicine
Symptoms as clues, not experiences, not suffering
From the Patient’s From the Patient’s Perspective- a Symptom Is Perspective- a Symptom Is
What Is BothersomeWhat Is Bothersome
Disease As a Clue for the Disease As a Clue for the SymptomSymptom
Disease process Symptom
Questions to ask…
How does the disease give rise to the symptom through local, central effects?
What are emotional, cognitive and spiritual components of the patient’s illness?
What Symptoms?What Symptoms?Constipation Diarrhea Peripheral Edema Nausea, vomiting Pruritus/itching Dyspnea Anxiety Anorexia Sleep disorders Cough Akathisia Dysphagia Anhedonia Death rattle/secretions Drooling Urinary Incontinence Rectal Incontinence Hiccups Flatulence Muscle spasms Confusion Memory Loss Visual problems Hearing loss Dysgeusia Colic Sexual dysfunction Polyuria Polydipsia Dizziness Dyspepsia Xerostomia Dry skin Dysarthria Dysphoria Dysuria Failure to thrive Fatigue Fear Fever Crying Hallucinations Halitosis Impotence Irritability Taste alterations Odor Mucositis Panic attacks Photosensitivity Restlessness Stomatitis Urinary frequency
N=53, Oxford Textbook of Palliative Medicine: Index, 1998.
Gut effect: Dysmotility of upper and lower gut– Doc(s): prokinetics
Effect on CTZ– Mediated through D2 receptor– Related to changing blood levels– Improves with steady state blood level– Doc(s): Haloperidol (po, inj.), Prochlorperizine (supp,
po)
Via two mechanisms:
No good evidence, rationale for using promethazine
5HT3 5HT3 AntagonistsAntagonists
Useful for certain forms of chemotherapy related nausea
May have other special uses:– In CTZ related nausea, where dopamine
blockade contraindicated– ? Other refractory CTZ related causes– ? In certain GI cases
Very expensive currently
DyspneaDyspnea
Common- 70% of dying patients in last six weeks of life
Traditional care for dyspnea largely palliative, as not curative– Focuses on lung physiology– Less attention to central processes
Pathophysiology of dyspnea poorly understood
Treating DyspneaTreating Dyspnea
Local– Low-dose opioids– Fan, cool breeze
Central– Low-dose opioids
Benzodiazepines for anxietyAddress emotional, cognitive, spiritual
factors
In addition to what you already know…
SUMMARYSUMMARY
Symptoms matter in their own right as expressions of patient suffering
Symptoms have their own “pathophysiology,”
As is true for treatment of disease, treatment of symptoms is tailored to this underlying physiology