Palliation of Non-Pain Symptoms in Cancer Care Palliative Care
Nov 06, 2015
Palliation of Non-Pain
Symptoms in Cancer Care
Palliative Care
The physician who sees his role only as the curer of
disease or the battler against death is often helpless;
the physician who knows that his function is to help the
sick to the limit of his ability is almost always able to
offer something. In his care, the sick are protected from
helplessness, fear, and loneliness, agonies that are
worse than death.
ERIC J. CASSEL, THE HEALERS ART, 1976, Chapter 7
Create the Best Palliative Care & EOL Experience for Patient, Family & Caregivers
Provide family guidance, support
Clinician - calm, supportive, communicative, provide appropriate referrals
Psychosocial & spiritual concerns
Physical
Objectives
At the end of this lecture, participants should be able to assess and manage some common physical symptoms in the context of supportive and palliative care: Pain
Dyspnea/Breathessness
Restlessness/Agitation/Delirium
Nausea/Vomiting
Respiratory Tract Secretions
Listen to the patient.
Make a diagnosis before treating.
Reflex prescription of an antiemetic to every patient with
nausea and vomiting, for example, will not benefit the patient
who is vomiting because of fecal impaction or because of
hypercalcemia.
In palliative care, as elsewhere in Medicine, choosing the most
appropriate treatment depends on the underlying pathology.
General Principles of Palliative Care in Advanced Cancer
Terminally ill patients are likely to have multiple (~7 to11) symptoms, most of which will be actual or potential sources of distress.
Ask the patient to describe every symptom.
Enlist the patients help to assign priorities to his problems:
What distresses you the most? The patients priorities, not the doctors, should govern the treatment plan.
Explore the significance that each symptom has for the patient.
Track symptoms at every visit.
Dyspnea
Anorexia-Cachexia Syndrome
Nausea and vomiting
Pain
Weakness and fatigue
Constipation
Ascites
Infection
Insomnia
Anxiety
Terminal Restlessness
Overview Of Palliative Care of Advanced Cancers
Explanation is part of the treatment.
Know the drugs that you use and know them well.
The informed and judicious use of pharmacologic agents is
the cornerstone of palliative medicine.
Learn the characteristics of the drugs, lest untoward drug
reactions or interactions aggravate the patients suffering.
Put it in writing.
Keep It Simple Please
Whenever possible, use
portmanteau
medications, i.e.,
medications that will
accomplish more than
one objective.
Drug Indications in Palliative
Care
Haloperidol
Nause & vomiting (among the
most potent inhibitor of the CTZ)
Confusional states & delirium
Diphenhydramine Vomiting & metabolically
related nausea (acts on the
vomiting center, vestibular
apparatus & cholinergic receptors
peripherally)
To combat extrapyramidal
effects of haloperidol &
metoclopramide
To provide mild sedation
Better if regimens are:
OD or BID than q4h or
q6h
Low technology
comfort measures
(such as hot water
bottles), than more
complicated & more
intimidating devices.
Assessment instruments
Visual analog scale (VAS)
Numeric Rating Scale (NRS)
Symptom inventories
Careful records
Physical Aspects of Palliative Care
Dyspnea/Breathlessness
Dyspnea etiology
Dyspnea is common, affecting 50-70% of cancer patients with life-limiting illness
As disease worsens, breathlessness occurs more frequently on exertion and at rest
Dyspnea worsens during the dying process
Anxiety can aggravate the symptom and fuel a progressive spiral of cause and effect
Challenge Highly subjective, complicating assessment Sensation of breathlessness that arises from a
combinations of: Underlying pathology Signaling of neural pathways Patient perception of physical sensations
Patient experience varies widely and depends partly on: Disease, Ethnic/racial background, Previous experience Emotional state
Often seems out of proportion, must be treated as reported
Current
evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, & of anxiolytics as adjuncts.
Kamal et al, J. of Palliative Medicine, 2012
Palliation of Respiratory Symptoms
Palliation of Respiratory Symptoms
Morphine and other opioids, given in small doses orally,
sublingually, or by injection, can provide dramatic relief for
many patients without causing respiratory depression.
- Ferraresi V., Am J Health-Syst Pharm.
2005;62(3):319-320.
Reduce anxiety Reduce sensitivity to
hypercapnea Improve cardiac
function Reduce concurrent
pain that may be a factor in producing anxiety and sensation of dyspnea
With proper titration, opioids can be used to relieve dyspnea by decreasing RR, while avoiding iatrogenic hypercarbia or hypoxia.
There were no events of respiratory depression or cognitive impairment in a frail, elderly population in a prospective study by Currow et al.
Kamal et al, J. of Palliative Medicine, 2012
Palliation of Dyspnea: Opioids (Morphine)
Opioid dosing for dyspnea Opioid nave:
Start at 20mg QD, sustained release morphine (assuming drug availability and no contraindications)
Increase to twice a day after 5-7 days if well tolerated
Opioid-tolerant, on morphine or opioid equivalent: Increase opioid by 20% of total daily dose every 3-5 days until
breathlessness is relieved or side effects
Patients with a morphine contraindication: Long acting oxycodone - 10mg QD Increase to BID after 5-7 days, as tolerated, if needed
Patients with AKI or CKD: Fentanyl
Severe, acute dyspnea: 2-5mg IV morphine every 5-10 minutes
Evidence Meta-analysis of 9 studies on use of opioids through 2001 to evaluate
effect on reliving dyspnea1: Highly statistically significant effect of oral and parenteral opioids on sensation of
breathlessness
Pooled effect size - 0.31, 95% CI -0.50 to -0.13, p=0.0008
Eight-day, randomized, double-blind, crossover clinical trial of 48 patients with refractory dyspnea2 20mg oral morphine sulfate (24-hr. sustained release) or placebo
1 outcome breathlessness sensation on a 100mm VAS
Mean baseline morning dyspnea score 43 (SD 26)
Morphine mean improvements of 6.6mm in morning (p=0.011) and 9.5mm in evening (p=0.006)
Relative improvement over baseline 15-22%
Morphine did not supress respiratory rate
Main side-effect was constipation 1Jennings AL et al. Thorax 2002;57:939-44. 2Currow DC, Abernethy AP et. al. British Medical Journal 2003;21; (327:1288c..
Other drugs for dyspnea-related symptoms
Benzodiazepines for patients with dyspnea that is aggravated by anxiety Midazolam, Alprazolam- short-acting Clonazepam- longer-acting control
Anti-tussives for coughing Anti-cholinergics (hyoscine n-butyl-bromide) to
minimize secretions Diuretics Bronchodilators Corticosteroids
Oxygen and non-pharmacologic management of dyspnea
Palliative oxygen -often prescribed but not effective
Recent multi-national, randomized controlled trial - palliative O2 found no difference in breathlessness with patients who received medical air through nasal cannulae
Fan
Psychosocial support to alleviate axiety and distress
Patient positioning
Pursed lip breathing
Relaxation techniques (e.g. massage, guided imagery)
Discuss symptom management with family, alleviate concerns, opioids may hasten death
Summary: Palliation of Dyspnea
Assessment is complicated due to highly subjective nature
Oral and parenteral opioids have a significant effect on breathlessness
Morphine alleviates sensation of breathlessness without reducing respiratory rate, but causes constipation
Medical gas may benefit, but not specifically oxygen
Physical Aspects of Palliative Care
Restleness/Agitation/Delirium
Identifying delirium Occurs in 28% to 83% of patients at EOL
Characterized by disturbance of consciousness, cognition, and perception.
Source of distress for the patient, loved ones, and care team.
Indirect result of various factors associated with the patients underlying cancer: Treatment side effects, metabolic disordering, nutritional deficiency, or infections
Opioid side-effects appear to be most common cause
Identifying Delirium
Two types of delirium:
Agitated/hyperactive delirium
Hypoactive delirium
Assessment scales:
Delirium Rating Scale
Confusion Assessment Method
Delirium Symptom Interview
Memorial Delirium Assessment Scale
Mini-Mental State Examination (MMSE)
Management
Discontinue all non-essential medication, especially psychoactive ones
Ensure not due to pain, urinary retention, or constipation.
Presence of family and loved ones, and familiar surroundings, help ease delirium
Avoid sedation or treating agitation, instead try to restore to baseline mental state
IV or oral Haloperidol - start at 0.5 mg bid
Other options: Chlorpromazine, Risperidone, and Olanzapine
Generally more expensive, no data showing they are more effective or safer
May use benzodiazepines (lorazepam, midazolam) but can worsen delirium
Physical Aspects of Palliative Care
Nausea / Vomiting (N/V)
Etiology
Some cancer patients continue to experience nausea and vomiting after treatment has been discontinued
N/V troubles up to 70% of cancer patients at EOL
Attempt to determine underlying cause and appropriate course to ease patients discomfort
N/V Contributing Factors
Opioid pain medications
Autonomic failure
Peptic ulcer disease
Constipation
Bowel obstruction
Metabolic abnormalities
Increased intracranial pressure
Pain
Strategies to consider
Select first-line anti-emetic and administer via a suitable route e.g. oral or if not, intravenous, SC, and intramuscular routes
Use anti-emetics regularly
Add second-line or combination therapy if symptoms persist
Address other, reversible, causes of N/V separately Hypercalcemia
Optimize renal function
Stop emetogenic therapies if possible
Treat delayed gastric emptying
Manage bowel obstruction
Management
Need to consider potential mechanism(s) of N/V and the site(s) of action
Metoclopramide for chronic nausea if bowel obstruction is not an issue
Dexamethasone and other corticosteroids can augment metoclopramide, 5-HT3 antagonists, and other anti-emetics effects
Benzodiazepines often effective
If bowel obstruction present, consider centrally active drugs like haloperidol and dimenhydrinate
Octreotide
Refractory nausea may respond to palliative sedation with midazolam
Causes of N/V
Anti-emetic Class of drug Example dose schedule
Common side-effects
Chemotx Acute emesis(24h) Ondansetron and/or Dexamethasone
5-HT3 antagonist
Corticosteroid
Ondansetron - 16mg PO, dexamethasone 8mg, daily in single or dividied doses
Constipation, headache Agitation/insomnia, gastric irritant
Prochlorperazine Dopamine antagonist
10mg PO or IV every 6 hours
Sedation, EPS
Anticipatory Lorazepam Benzodiazepine 12 mg PO or IV prn, max 4 mg/24 h
Sedation
Iatrogenic, e.g. opiates
Metaclopramide
Haloperidol
Prokinetic Dopamine antagonist
10mg PO or IV every 8 hours prn 1.53 mg PO every 8 hours prn
Agitation Sedation, extrapyramidal effects (EPS)
Gastric irritation including Radiotx
Lansoprazole Ondansetron
Prochlorperazine
Proton pump inhibitor 5-HT3 antagonist
Dopamine
30 mg PO daily 4-8 mg PO every 8 hours prn
10mg PO or IV every 6 hours prn
Constipation, headache
Sedation, extrapyramidal
Physical Aspects of Palliative Care
Respiratory Tract Secretions
Situation
Common at EOL - occurring in up to 90% of unconscious patients1-4
Respiratory tract secretions are a strong predictor of death - 48% within 24-hours and 76% within 48-hours of onset
May not be distressing to patient at EOL but troubling for those at the bedside
Cause- oscillatory movements of accumulated bronchial mucosa and salivary secretions that the patient is unable to clear
Avoid using the term death rattle with family, consider congestion instead
Non-pharmacologic treatment
Reposition - supine to lateral recumbent with head slightly raised
Suction sparingly - most secretions are below the larynx and inaccessible & frequent suctioning can be unsettling to patient and family
Communication with the family about what is happening
Pharmacologic management
Anticholinergic/antisecretory agents (Hyoscine n-butyl- bromide 10-20 mg p.o. or IV q6h-q8h), may be effective in reducing saliva and mucus production - use at first sign since they are not effective on existing secretions
Muscarinic receptor blockers; use sparingly side effects are substantial Scopolamine patch
Glycopyrrolate
Atropine
Terminal Care: Nutrition & Hydration
During the last days of life, patients tend naturally to take in less and less food and fluid.
Hunger is rare in the last days of life.
Thirst occurs more commonly, but without relation to dehydration, and can usually be controlled by simple measures (e.g., moistening the lips, giving small sips of fluids or small amounts of crushed ice to suck).
Enteral feeding should be stopped when the patient can no longer swallow reliably.
Terminal Care: Hydration
In most cases, parenteral (IV) fluids should not be given in the last hours of life.
Allowing the patient to become slightly dehydrated may prevent or ameliorate many otherwise distressing problems in the last hours:
Consequence of IV
Hydration
Symptoms
Respiratory secretions Cough Pulmonary congestion
Sensations of choking & drowning
Urine Output Bedwetting, bedpans, catheters
Gastrointestinal secretions Vomiting
Total body water Edema, ascites, pleural effusions
Serum urea Awareness Distress, Pain threshold
Psychosocial Support of the Patient and the Family
In addition to anxiolytics and antidepressants, supportive counseling, spiritual counseling, and family support can help counter feelings of depression and anxiety
There is nothing more that can be done does not exist in the lexicon of palliative medicine
There is always something that can be done, even if it is simply to sit beside the patient and hold her hand and offer a few words of comfort and solidarity.
1) To see the patient & the family through
- the physical & emotional stages of terminal illness
2) To ease their burden along the way
- to walk alongside, not to give orders from above
3) To be there
- when symptoms arise, when hard questions have
to be faced, when fear & loneliness threaten
TASKS OF THE MULTIDISCIPLINARY
PALLIATIVE CARE TEAM
TASKS OF THE MULTIDISCIPLINARY
PALLIATIVE CARE TEAM
To apply to the care of the chronically-ill,
the terminally-ill, &
the dying
the same high standards
of clinical analysis &
decision-making as are
demanded in the care of
patients expected to
get well
Death is not extinguishing the light;
it is putting out the lamp because the Dawn has come.
- Rabindranath Tagore
ACKNOWLEDGEMENT:
Some content of the slides adapted from:
Amy P. Abernethy, MD Division of Medical Oncology
Department of Medicine
Duke University Medical Center, USA