Supportive and Palliative Care Pharmacology Toolkit for Non-Pain Symptom Management Shirley Brogley March 24, 2017

Objectives Identify 3 major non pain symptoms that are most problematic for the palliative patient Name 2 interventions for the management of each of the 3 major non pain symptoms

There are many physical and psychological symptoms for Palliative patients Ongoing assessment and evaluation is needed Requires interdisciplinary teamwork

Symptoms create suffering and distress Psychological intervention is key to complement pharmacologic strategies

Common Symptoms Respiratory Dyspnea Cough Excessive Secretions

GI Anorexia Constipation Diarrhea Nausea/Vomiting Obstruction

General/Systemic Fatigue Weakness Insomnia

Psychological Depression Anxiety Delirium

Dyspnea A subjective experience of a person’s breathing, only truly reported by the patient Distressing shortness of breath, impaired gas exchange Their work/effort, tightness of chest, air hunger Evokes distinct emotions and behaviors in an individual

Imagine how you feel after a 20 minute run on treadmill, that is how the patient feels

Causes Pulmonary Cardiac Neuromuscular Other

Assessment Use subjective report-patient may report gasping, smothering or suffocating Clinical assessment Physical exam Diagnostic tests

Treatment Treating symptoms or managing underlying cause Pharmacologic treatments Opioids Bronchodilators Diuretics Antianxiety

Nonpharmacologic Oxygen Fans, open windows Elevation, compromised lung down Relaxation techniques Pursed lip breathing Energy conservation Adjust humidity, humidifier or air conditioning

Opioid Therapy Best agent for dyspnea Suppresses sensation of shortness of breath Oral opioids, prn or continuous infusion Respiratory depression uncommon as it is almost always preceded by drowsiness

Morphine-concentrated via po/sl or IV, start low, go slow Morphine can also relieve cough Antianxiety meds-, Lorazepam if anxiety or panic is a component

Cough Common symptom in advanced disease Causes pain, fatigue, insomnia

Causes of Cough Assess underlying cause- infection, reflux, sinusitis Assess associated symptoms-sputum

Pharmacologic Interventions for Cough Suppressants/expectorants Antibiotics Steroids Anticholinergics

Non Pharmacologic Interventions for Cough Chest PT Humidifier Positioning

Excessive Secretions Secretions collect as the patient is unable to clear or swallow. As patient is unresponsive and breath, air is drawn through accumulating mucous, causing gurgling sound

Frequently seen with Lung Cancer CHF COPD Pulmonary Fibrosis ALS MS Dementia

Pharmacologic Interventions Antibiotics Bronchodilators Mucolytic agents-thin secretions Antihistamines Steroids

Drying Agents Scopolamine Patch-one to three patches, change every 72 hours Glycopyrrolate- 0.2-0.4 mg IV or SC every 4-8 hours prn Atropine 1% Opthalmic drops- 1-2 drops SL every 1-2 hours Hyoscyamine 0.125 ODT PO/SL every 4 hours Avoid suction if possible-irritating, can increase secretions

Causes of Anorexia and Cachexia Disease related Psychological Treatment related

Assessment Physical findings Impact on function and QOL Calorie counts/weights Lab tests

Treatment Dietary consultation Medications Parenteral/enteral nutrition Odor control Counseling

Constipation Infrequent passage of stool Frequent symptom in palliative care Prevention is key

Causes Disease related-obstruction, hypercalcemia, neurologic, inactivity Treatment related-opioids and other meds Poor intake, low fiber, low fluids, impaired mobility

Assessment Bowel history Abdominal assessment Rectal assessment if appropriate Medication review

Treatment Medications- stool softener and stimulant- maintain patient on a bowel regimen Bulk forming agents may not be effective in palliative care due to decreased fluid intake

Medications Miralax Senokot Glycerin or Dulcolax suppository Lactulose MOM Mag. Citrate Enemas-tap water, soap suds, mineral oil Methylnaltrexone- dosed by body weight

Diarrhea Frequent passage of loose, non formed stool Effects- fatigue, caregiver burden, skin breakdown

Causes Disease related Malabsorption Concurrent diseases Psychological Treatment related

Assessment Bowel history Medication review Infection process

Treatment Treat underlying cause Dietary modifications Hydration Pharmacologic agents

Nausea and Vomiting Common in advanced disease Assessment of etiology is important Acute, anticipatory or delayed Impacts Quality of Life

Causes Physiological- metabolic, CNS Psychological Disease related Treatment related Other

V- vestibular, motion O- obstruction, constipation M- mind, anxiety I- infection, inflamanation T- toxins, opioids, uremia

Assessment Physical exam History Lab values

Pharmacologic Treatment Anticholinergics Antihistamines Steroids Prokinetic Agents Other

GI, Chemoreceptor Trigger Zone, Metabolic (Renal or Liver failure or tumor products) Haloperidol, start at 0.5mg SC or PO every 6-12 hours and can increase

CNS, Increased Intracranial pressure Dexamethasone 4-8mgPO/SC/IV q 4-8 hours

Anxiety Lorazepam 0.5 mg PO/SC/IV every 4-8 hours, titrating dose as needed

Vestibular Meclizine or hydroxyzine 25 mg PO TID

Non Drug Treatment Distraction Dietary Small/slow feedings

Obstruction Abdominal distention Pain Fecal incontinence Cramping Blood in stool Weak, weight loss Vomiting

Treatments Octreotide- 50 mcg to 200 mcg SC TID or continuous infusion starting at 10-20 mcg/hour, inhibits peristalsis, decreases secretion of fluids Metoclopramide 60-240 mg/day, SC/PO/IV- increases motility of GI tract Simethicone for bloating- 40-125 mg, 4xday, after meals and at bedtime

Fatigue Subjective, multidimential experience of exhaustion Commonly associated with many diseases Impacts all dimensions of QOL

Causes Disease related Psychological Treatment related

Assessment Subjective Objective Lab data

Treatment Pharmacologic- Methylphenidate 2.5-5mg at 8am and noon, can titrate to 10-60mg/day, avoid use in cardiac patients with preexisting arrhythmia Nonpharmacologic- rest, energy conversation, PT/OT

Depression Ranges from sad to suicidal Often unrecognized and undertreated Occurs in 25-77% of terminally ill patients Distinguish between normal and abnormal

Causes Disease related Psychological Treatment related

Assessment Situational factors Previous psychiatric history Other factors- lack of support system, pain

Suicide Assessment Do you feel life isn’t worth living? Have you thought about how you would end your life? (Do you have a plan?)

Pharmacologic Interventions Antidepressants- Mirtazapine 15 mg at bedtime, may slowly titrate (every 1-2 weeks) up to 45mg/day Stimulants Steroids

Non Pharmacologic Promote autonomy Grief counseling Draw on strengths; reframing Focus on hopes Utilize chaplain

Anxiety Subjective feeling of apprehension Often without specific cause Categories of mild, moderate and severe

Causes Medications Uncertainty

Assessment Physical symptoms Cognitive symptoms

Pharmacologic Interventions Antidepressants Benzodiazepines/anticonvulsants Neuroleptics

Non Pharmacologic Interventions Empathetic listening Assurance and support Concrete information Relaxation/imagery

Delirium/Agitation/Confusion Delirium-acute/sudden change in cognition/awareness Agitation-accompanies delirium Confusion-disorientation, inappropriate behavior, hallucinations

Causes Infection Medications Hypoxemia Bladder distention Constipation

Assessment Physical exam History Spiritual distress Other symptoms

Treatment Pharmacologic Evaluate medications Reorientation Relaxation/distraction Hydration

Nursing Roles Advocacy Assessment Pharm tx Non-Rx tx Pt./family teaching

Conclusion Multiple symptoms are common Coordination of care with all other providers Use med and non-med treatment Patient/family support

Questions????

Shirley Brogley ACHPN, ANP-BC Supportive and Palliative Care, HFG Cancer Center sbrogley@christianacare.org 302-623-4960