Palliative Management Of: • Nausea And Vomiting • Dyspnea • Secretions • Delirium Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor, University of Manitoba Faculty of Medicine
Mar 27, 2015
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