PALLIATIVE CARE SYMPTOM MANAGEMENT Patricia Ford MD Medical Director Community Hospice of Saratoga.

PALLIATIVE CARE

SYMPTOM MANAGEMENTPatricia Ford MD

Medical Director

Community Hospice of Saratoga

OBJECTIVES:

Review common non-pain symptoms experienced by patients with chronic, progressive and life-limiting illnesses

Identify causes of those symptoms Learn interventions to treat symptoms using

both drug and non-drug treatment modalities

COMMON SYMPTOMS

Dyspnea Nausea/Vomiting Excess Secretions Agitation/Delirium Constipation

DYSPNEA

Definition: A subjective sensation of difficulty breathing; an abnormally uncomfortable awareness of breathing

25% of ambulatory patients and over 50% of inpatients have dyspnea

Mr Jones 78 yo with ES COPD on home hospice. Bed

to chair with marked dyspnea. Dyspneic with conversation.

Meds: Advair, Spiriva, Combivent, prednisone 10 mg daily

Albuterol nebulizer was added – using this about 5 times/day with some relief

Continuous supplemental O2 at 2 lit/NC

Mechanism of Dyspnea

Hypoxemia, bronchoconstriction, hyper-inflation stimulate sensory receptors

CNS processes information – sends impulse to respiratory muscles

Mismatch between afferent information from various receptors and the respiratory motor activity - dyspnea

Causes of Dyspnea

tracheal obstruction, asthma, COPD, aspiration, diffuse primary or metastatic cancer, lymphangitic metastases, pneumonia, pleural effusion, pneumothorax, pulmonary drug reaction, radiation pneumonitis

Treating the Underlying Cause

COPD -MDI’s not effective in severe casesAerochambers may help Nebulizers are preferred Inhaled steroids may be stopped in patients

on chronic oral steroids CHF – titrate nitrates/diuretics

DYSPNEA in Palliative Care

Non-Drug Treatments• Positioning - sitting up• Bedside fan• Pursed lip breathing• Humidified air• Noninvasive positive pressure mask

DYSPNEA

Treatment with Oxygen• Think of oxygen as any other drug - not all dyspneic

patients benefit• Pulse oximetry will generally not be of benefit in

decision-making for treating terminal dyspnea• Masks and positive pressure devices are poorly

tolerated; use nasal cannula or nasal high flow• For end of life, use 2-4 liters of oxygen; for continued

dyspnea use drug therapy rather than using higher flow rates or face mask

High Flow O2 vs BiPAP for Dyspnea in Advanced Cancer HFO: Delivers up to 40L/min humidified heated O2

Provides naso-pharygneal washout and positive distending pressure

Decreases airway resistance and the metabolic cost of breathing

BiPAP: Also assists ventilation and unloads respiratory muscles – may stimulate trigeminal nerve

Study Results

Dyspnea improved with both – lasted for two hours

Non-significant decrease in resp rate BiPAP – decreased heart rate HFO – decreased BP and improved O2 No adverse effects – less trouble sleeping

on HFO vs BiPAP

DYSPNEA

Drug therapy – mainstay is opioids• Acutely increase exercise tolerance • Reduce minute ventilation• Reduce subjective sense of breathlessness• Small doses can be effective:

5-10 mg of oral morphine in opioid naïve patients; for severe dyspnea or when patients are unable to swallow, 1-5 mg morphine IV q 10 minutes

• Other opioids are also useful for dyspnea

•

Opiate Titration

As with pain, titrate to comfort. (tachypnea may persist)

May use long acting preparations ex. Morphine sulfate extended release or fentanyl patch with short acting opiate for breakthrough dyspnea

Morphine and Respiratory Depression Sedation precedes respiratory depression. Low dose opioids can be used in advanced COPD to enhance

quality of life. Opioid dose can be titrated up at the end of life when needed for

symptom control. This is not euthanasia or assisted suicide. Ethically, the use of these drugs is appropriate and essential, as

long as the intent is to relieve distress, rather than shorten life. There is no justification for withholding symptomatic treatment

to a dying patient out of fear of potential respiratory depression.

Mr Jones 78 yo with ES COPD on home hospice. Bed

to chair with marked dyspnea. Dyspneic with conversation.

Meds: Advair, Spiriva, Combivent, prednisone 10 mg daily

Albuterol nebulizer was added – using this about 5 times/day with some relief

Continuous supplemental O2 at 2 lit/NC

Treatment Modifications

Discontinue spiriva/advair/combivent Albuterol/ipratropium nebulizer q 4h Albuterol nebulizer prn +/- increase supplemental O2 to 3 lit/NC Morphine 5 – 10 mg po q 1 hr prn Fan across the face prn/relaxation

techniques/ pursed lip breathing

Role of Anxiolytics

Anxiolytics- benzodiazepines (e.g. lorazepam) may help relieve the anxiety associated with dyspnea

Possibly blunt ventilatory drive When combined with opioids, will produce

additive sedative/CNS depressant effects which may or may not be desirable

Nausea/Vomiting

Occurs in 62% of cancer patients Present in 40% opioid treated patients Under reported and under treated Anorexia may represent chronic low grade

nausea

The Case of Mrs. Rubio 72 yo with lung cancer with metastases to

adrenals, bone and brain Disease progression despite treatment Recent whole brain radiation Admitted to hospice – 30 lb weight loss, fatigue

and weakness Pain well managed on MS Contin 60 mg bid +

MSIR for BTP Occasional nausea – prn promethazine

Common Causes of Nausea and Vomiting in Hospice patients Chemical: metabolic, drugs, infections Visceral and serosal causes: bowel

obstruction, GI bleed, enteritis, constipation

Increased intracranial pressure, anxiety, meningeal irritation

Labyrinth disorders

Mechanisms of NauseaChemicals Affect D2, 5HT3, NK1 receptors – stimulate the

chemoreceptor trigger zoneMechanical/GI Affect 5HT3, mechanoreceptors and chemical

receptors in GI tract – peripheral pathwaysLabyrinth disorders – Achm, H1 – stimulates the

vestibular systemCortex – anxiety, meningeal irritation, increased

ICP Stimulate the vomiting center in the brainstem

NAUSEA / VOMITING

Common causes of nausea• Obstruction• Gastritis, GERD• Gastric stasis• GI infection• Constipation• Abdominal carcinomatosis, extensive liver metastases• Acute effect of abdominal radiation or chemotherapy• Ascites – squashed stomach syndrome

NAUSEA / VOMITING

Other causes of nausea• CNS - elevated ICP, posterior fossa tumors/bleed,

infectious or neoplastic meningitis• Drugs - opioids, chemotherapy, antibiotics• Metabolic - hypercalcemia, liver failure, renal failure,

sepsis• Psychological - anxiety, pain, conditioned response

(e.g. anticipatory nausea/vomiting)

Often multi-factorial

NAUSEA / VOMITING

Treatment with Non-Drug Therapy• GI drainage for obstruction• Fluid management – GI obstruction may

improve by reducting parenteral fluids to decrease GI secretions

Non-pharmacologic Interventions Avoid strong food smells Small frequent meals NPO during and for a while after periods of

vomiting occur. Wrist bands Relaxation techniques - imagery, music,

distraction, games Accupuncture/accupressure

NAUSEA / VOMITING – Drug Therapy

Try to match the cause of nausea with the most appropriate drug class

If primary cause is Stimulation of CTZ : Start with aD2 receptor antagonist:

metoclopramide, prochlorperazine or haloperidol

If ineffective, add a 5HT3 antagonist: odansetron, mirtazapine

Other Treatments for Nausea

Anxiety – may add benzodiazepine Elevated ICP – glucocorticoid Gastric Stasis – metoclopramide Constipation – treat the constipation Bowel Obstruction – octreotide, venting

PEG tube, surgery Vestibular – scopalamine patch

The Case of Mrs. Rubio 72 yo with lung cancer with metastases to

adrenals, bone and brain 30 lb weight loss – anorexia may represent

chronic low grade nausea Morphine may contribute to nausea

Recommendations:Consider dexamethasone

Odansetron + prochlorperazine around the clock

Consider opiate rotation

Pearls in Treating Nausea

Make the anti-emetic around the clock Use combination therapy when needed –

work on different receptors Promethazine is only a weak anti-emetic Manage constipation if present

EXCESS SECRETIONS

Respirations may become congested or gurgling, especially when death is imminent• Caused by a decline in the gag reflex function and

reflexive clearing of the oropharynx• Secretions from the tracheobronchial tree accumulate

and the patient is too weak or unable to swallow or expectorate the secretions

• Often the healthcare professionals and the family members are more affected by the noisy breathing than the patient

EXCESS SECRETIONS

Treatments• Suctioning the patient is not recommended, as it is

ineffective and often uncomfortable for the patient• Turn the patient on his/her side• Elevate the head of the bed• Reassure the family of the patient’s comfort• Educate the family about the etiology of the breathing• Anticholinergics, such as scopolomine, glycopyrrolate

and hyoscyamine can be useful in reducing secretions

Treatment of oral secretions

Drug Trade name

Route Starting dose

Onset

Hyoscyca-mine

Scopala-mine

Trans-dermal

1patch 12 hrs

Atropine Multiple Sub-lingual

1 drop 30 min

Glycopyr-rolate

Robinul Oral 1 mg 30 min

Glycopyr-rolate

Robinul SC, IV .1 mg 30 min

Common Errors

Using both scopalamine and atropine Adding an anti-cholinergic then treating

subsequent agitation with benzodiazepines

Adding atropine for respiratory congestion in a patient that is not terminal.

AGITATION / DELIRIUM

Definition - An acute altered level of consciousness associated with:• Reduced attention and memory• Perceptual disturbances• Incoherent speech• Altered sleep-wake cycles

The Case of Mr. Coons

45 year old with ESLD secondary to Hepatitis C and alcoholic liver disease

Ascites requiring frequent paracentesis Hepatic encephalopathy resistant to

lactulose and rifaximin Increased agitation – lorazepam makes it

worse

Confusion Assessment Method

Digit span-repeat 3, then 4, then 5 numbers

Read letters – patient taps with ‘A’ Can a rock float? Are there fish in the sea?

Is one pound more than two pounds? Do you use a hammer to pound a nail?

“Hold up this many fingers” each hand

AGITATION / DELIRIUM

Hyperactive Delirium• Agitated, picking at clothes and bed covers,

rambling and loud incoherent speech Hypoactive Delirium

• Quiet, sleepy, little spontaneous movement, soft incoherent speech

AGITATION / DELIRIUM

D – drugs E – eyes and ears L – low flow states I – Intracranial R – retention I – infection U – under – hydration/nutrition/sleep M – metabolic and toxic

AGITATION / DELIRIUM

Treatment - Non-Drug• Quiet, peaceful room• Family member present to relieve anxiety• Avoid physical restraints• Assess for unresolved psychological or

spiritual issues, unfinished business• Holistic therapy

AGITATION / DELIRIUM

Treatment with Drug Therapy• The primary drug class for terminal delirium are the

major tranquilizers (e.g. haloperidol)• Although benzodiazepines are commonly used, they

may lead to paradoxical worsening of the delirium• Dosing is similar to opioids for pain – give enough to

reduce the target symptom, there is no maximum dose

Starting dose of haloperidol is 1-2 mgs, can be given every hour as needed to reduce symptoms until the patient has stabilized, then converted to a dose given every 6-12 hours

Atypical Antipsychotics

Risperidone .25-1 mg taken BID to q 6 hrs Caution with renal failure

Olanzapine 2.5-10 mg taken daily Not in CNS malignancy, hypoactive, over 70

Quetiapine 12.5 – 50 mg taken bid Dosing 4 pm and hs – most sedating

Aripiprazole 5-15 mg taken q am Useful for hyperactive – can cause insomnia

The Case of Mr. Coons

45 year old with ESLD secondary to Hepatitis C and alcoholic liver disease

Ascites requiring frequent paracentesis Hepatic encephalopathy ‘resistant to

lactulose and rifaximin’ Increased agitation – lorazepam makes it

worse

Mr Coons

Haldol 1 mg q 1 hr x 3 doses then 2 mg q 6 hrs around the clock

Correct hyponatremia Lactulose – ‘do not hold’ Discontinue diazepam and zolpidem Improve pain management Indwelling Pleurx catheter to manage ascites

Constipation

“Constipation” can mean different things to different people• Acute: recent decrease in frequency or

increase in difficulty starting a bowel movement, duration less than 6 months

• Chronic: less than 3 BM’s per week, duration more than 6 months

Constipation In addition to complaining of

“constipation”, patients also complain of:• Stool that is small or hard• Stool that is not completely evacuated• Increased gas• Abdominal or rectal pain• Change in stool character• Anorexia and early satiety

Causes of Constipation Drugs

• Opioids• Anti-cholinergics: (antidepressants,

neuroleptics, anti-emetics, anti-histamines) Metabolic

• Hypercalcemia, diabetes, hypothyroidism, uremia

Neurologic• Spinal cord lesions

Causes of Constipation (cont’d)

Mechanical• Obstruction or pseudo-obstruction (Ogilvie’s)• Ascites• Carcinomatosis

Causes of Constipation (cont’d)

Miscellaneous• Pain - generalized or rectal• Lack of privacy or awkward positioning

(bedpan)• Loss of normal bowel routine• Lack of fluid intake• Delirium

Opioid-Induced Constipation

Little tolerance to constipation develops Start bowel protocol when opioids are initiated Optimal dose is unknown Fentanyl and methadone may cause less

constipation than morphine Methylnaltrexone (Relistor©) - Sub Q injection

to reverse OI constipation

Constipation: Key Assessment Issues

Fecal Impaction? Constipation vs. Obstruction? Neurological Process? Fluid/Electrolye problem?

Management of Constipation

General measures Increase fluid intake Restore daily bowel routine Ensure privacy Ensure a comfortable position Reverse treatable causes Prophylaxis when possible

Drug Therapy for Constipation

Laxatives/Stimulants Bulk agents Lubricants Hyperosmotic agents Prokinetic drugs “Natural” laxatives Enemas

Laxatives / Stimulants

Senna Bisacodyl (Dulcolax ®) Detergent laxatives “wetting agents”

Colace ®, Surfak ®

Castor oil is a detergent laxative that is not recommended for use.

Lubricants

Mineral Oil• Can be used for fecal impaction or acute

constipation• Causes malabsorption with prolonged use• Do not use with docusate products

Hyperosmotic and Saline Agents

Agents that pass through the small bowel and draw water into the colon• Sugars: lactulose, sorbitol, mannitol, glycerin• Saline agents: Polyethylene glycol

(Miralax ®), magnesium, sulfate, and phosphate preparations

Enemas

Saline (Fleets®) Tap water or soap suds Oil-retention Other

Natural Laxatives

Prunes or prune juice Dates and figs Raisins Apples Senna Other

Pearls in Treating Constipation at the End of Life Do not add fiber in patient with poor fluid

intake (soft impaction) Poor motility is common – senna is useful Docusate is generally ineffective alone Miralax works well, but can cause

dehydration

REFERENCES

Wood GJ et al Mgt of intractable nausea nad vomiting in patients at the end of life JAMA 2007; 298(10) 1196-1207

Breitbart W, Alici Y, Agitation and Delirium at the End of Life JAMA Dec 2008

McPhee et al, Care at the Close of Life: Evidence and Experience, JAMA Archives and Journals 2011

Panke, J., Coyne, P. (2006) Conversations in Palliative Care. Pittsburgh, PA: Hospice and Palliative Nurses Association

References continued

Wrede-Seaman, L. (2005) Symptom Management Algorithms A handbook for Palliative Care. Yakima, Washington: Intellicard

Weissman, D.(2006) Palliative Care: Presentations for Medical Educators. Medical College of Wisconsin

Hui, D et al. (2013) High-Flow Oxygen and Bilevel Positive Airway Pressure for Persistent Dyspnea in Patients with Advanced Cancer: A Phase II Randomized Trial. Journal of Pain and Symptom Management Vol 46 No. 4, October 2013