EPECEPECEPECEPEC EPECEPECEPECEPEC Common Physical Symptoms Common Physical Symptoms Module 10 The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation

Objectives l Know general guidelines for managing nonpain symptoms l Understand how the principles of intended / unintended consequences and double effect apply to symptom management l Know the assessment, management of common physical symptoms l Know general guidelines for managing nonpain symptoms l Understand how the principles of intended / unintended consequences and double effect apply to symptom management l Know the assessment, management of common physical symptoms

General management guidelines... l History, physical examination l Conceptualize likely causes l Discuss treatment options, assist with decision making l History, physical examination l Conceptualize likely causes l Discuss treatment options, assist with decision making

... General management guidelines l Provide ongoing patient, family education, support l Involve members of the entire interdisciplinary team l Reassess frequently l Provide ongoing patient, family education, support l Involve members of the entire interdisciplinary team l Reassess frequently

Intended vs unintended consequences l Primary intent dictates ethical medical practice

Breathlessness (dyspnea)... l May be described as shortness of breath a smothering feeling inability to get enough air suffocation l May be described as shortness of breath a smothering feeling inability to get enough air suffocation

... Breathlessness (dyspnea) l The only reliable measure is patient self-report l Respiratory rate, pO 2, blood gas determinations DO NOT correlate with the feeling of breathlessness l Prevalence in the life-threateningly ill: 12 – 74% l The only reliable measure is patient self-report l Respiratory rate, pO 2, blood gas determinations DO NOT correlate with the feeling of breathlessness l Prevalence in the life-threateningly ill: 12 – 74%

Causes of breathlessness l Anxiety l Airway obstruction l Bronchospasm l Hypoxemia l Pleural effusion l Pneumonia l Pulmonary edema l Anxiety l Airway obstruction l Bronchospasm l Hypoxemia l Pleural effusion l Pneumonia l Pulmonary edema l Pulmonary embolism l Thick secretions l Anemia l Metabolic l Family / financial / legal / spiritual / practical issues

Management of breathlessness l Treat the underlying cause l Symptomatic management oxygenopioidsanxiolytics nonpharmacologic interventions l Treat the underlying cause l Symptomatic management oxygenopioidsanxiolytics nonpharmacologic interventions

Oxygen l Pulse oximetry not helpful l Potent symbol of medical care l Expensive l Fan may do just as well l Pulse oximetry not helpful l Potent symbol of medical care l Expensive l Fan may do just as well

Opioids l Relief not related to respiratory rate l No ethical or professional barriers l Small doses l Central and peripheral action l Relief not related to respiratory rate l No ethical or professional barriers l Small doses l Central and peripheral action

Anxiolytics l Safe in combination with opioids lorazepam mg po q 1 h prn until settled then dose routinely q 4–6 h to keep settled l Safe in combination with opioids lorazepam mg po q 1 h prn until settled then dose routinely q 4–6 h to keep settled

Nonpharmacologic interventions... l Reassure, work to manage anxiety l Behavioral approaches, eg, relaxation, distraction, hypnosis l Limit the number of people in the room l Open window l Reassure, work to manage anxiety l Behavioral approaches, eg, relaxation, distraction, hypnosis l Limit the number of people in the room l Open window

Nonpharmacologic interventions... l Eliminate environmental irritants l Keep line of sight clear to outside l Reduce the room temperature l Avoid chilling the patient l Eliminate environmental irritants l Keep line of sight clear to outside l Reduce the room temperature l Avoid chilling the patient

... Nonpharmacologic interventions l Introduce humidity l Reposition elevate the head of the bed move patient to one side or other l Educate, support the family l Introduce humidity l Reposition elevate the head of the bed move patient to one side or other l Educate, support the family

Nausea / vomiting l Nausea subjective sensation stimulation gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex l Vomiting neuromuscular reflex l Nausea subjective sensation stimulation gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex l Vomiting neuromuscular reflex

Causes of nausea / vomiting l Metastases l Meningeal irritation l Movement l Mental anxiety l Medications l Mucosal irritation l Metastases l Meningeal irritation l Movement l Mental anxiety l Medications l Mucosal irritation l Mechanical obstruction l Motility l Metabolic l Microbes l Myocardial

Pathophysiology of nausea / vomiting CortexCortex Vestibular apparatus GI tract Chemoreceptor Trigger Zone (CTZ) Neurotransmitters l Serotonin l Dopamine l Acetylcholine l Histamine Neurotransmitters l Serotonin l Dopamine l Acetylcholine l Histamine Vomiting center

Management of nausea / vomiting l Dopamine antagonists l Antihistamines l Anticholinergics l Serotonin antagonists l Dopamine antagonists l Antihistamines l Anticholinergics l Serotonin antagonists l Prokinetic agents l Antacids l Cytoprotective agents l Other medications

Dopamine antagonists l Haloperidol l Prochlorperazine l Droperidol l Thiethylperazine l Promethazine l Perphenazine l Trimethobenzamide l Metoclopramide l Haloperidol l Prochlorperazine l Droperidol l Thiethylperazine l Promethazine l Perphenazine l Trimethobenzamide l Metoclopramide

Histamine antagonists (antihistamines) l Diphenhydramine l Meclizine l Hydroxyzine l Diphenhydramine l Meclizine l Hydroxyzine

Acetylcholine antagonists (anticholinergics) l Scopolamine

Serotonin antagonists l Ondansetron l Granisetron l Ondansetron l Granisetron

Prokinetic agents l Metoclopramide l Cisapride l Metoclopramide l Cisapride

Antacids l Antacids l H 2 receptor antagonists cimetidinefamotidineranitidine l Proton pump inhibitors omeprazolelansoprazole l Antacids l H 2 receptor antagonists cimetidinefamotidineranitidine l Proton pump inhibitors omeprazolelansoprazole

Cytoprotective agents l Misoprostol l Proton pump inhibitors (omeprazole, lansoprazole) l Misoprostol l Proton pump inhibitors (omeprazole, lansoprazole)

Other medications l Dexamethasone l Tetrahydrocannabinol l Lorazepam l Octreotide l Dexamethasone l Tetrahydrocannabinol l Lorazepam l Octreotide

Constipation l Medications opioids calcium-channel blockers anticholinergic l Decreased motility l Ileus l Mechanical obstruction l Medications opioids calcium-channel blockers anticholinergic l Decreased motility l Ileus l Mechanical obstruction l Metabolic abnormalities l Spinal cord compression l Dehydration l Autonomic dysfunction l Malignancy

Management of constipation l General measures establish what is “normal” regular toileting gastrocolic reflex l General measures establish what is “normal” regular toileting gastrocolic reflex l Specific measures stimulantsosmoticsdetergentslubricants large volume enemas

Stimulant laxatives l Prune juice l Senna l Casanthranol l Bisacodyl l Prune juice l Senna l Casanthranol l Bisacodyl

Osmotic laxatives l Lactulose or sorbitol l Milk of magnesia (other Mg salts) l Magnesium citrate l Lactulose or sorbitol l Milk of magnesia (other Mg salts) l Magnesium citrate

Detergent laxatives (stool softeners) l Sodium docusate l Calcium docusate l Phosphosoda enema prn l Sodium docusate l Calcium docusate l Phosphosoda enema prn

Prokinetic agents l Metoclopramide l Cisapride l Metoclopramide l Cisapride

Lubricant stimulants l Glycerin suppositories l Oils mineralpeanut l Glycerin suppositories l Oils mineralpeanut

Large-volume enemas l Warm water l Soap suds l Warm water l Soap suds

Constipation from opioids... l Occurs with all opioids l Pharmacologic tolerance developed slowly, or not at all l Dietary interventions alone usually not sufficient l Avoid bulk-forming agents in debilitated patients l Occurs with all opioids l Pharmacologic tolerance developed slowly, or not at all l Dietary interventions alone usually not sufficient l Avoid bulk-forming agents in debilitated patients

... Constipation from opioids l Combination stimulant / softeners are useful first-line medications casanthranol + docusate sodium senna + docusate sodium l Prokinetic agents l Combination stimulant / softeners are useful first-line medications casanthranol + docusate sodium senna + docusate sodium l Prokinetic agents

Causes of diarrhea l Infections l GI bleeding l Malabsorption l Medications l Obstruction l Overflow incontinence l Stress l Infections l GI bleeding l Malabsorption l Medications l Obstruction l Overflow incontinence l Stress

Management of diarrhea l Establish normal bowel pattern l Avoid gas-forming foods l Increase bulk l Transient, mild diarrhea attapulgite bismuth salts l Establish normal bowel pattern l Avoid gas-forming foods l Increase bulk l Transient, mild diarrhea attapulgite bismuth salts

Management of persistent diarrhea l Loperamide l Diphenoxylate / atropine l Tincture of opium l Octreotide l Loperamide l Diphenoxylate / atropine l Tincture of opium l Octreotide

Anorexia / cachexia l Loss of appetite l Loss of weight l Loss of appetite l Loss of weight

Management of anorexia / cachexia... l Assess, manage comorbid conditions l Educate, support l Favorite foods / nutritional supplements l Assess, manage comorbid conditions l Educate, support l Favorite foods / nutritional supplements

... Management of anorexia / cachexia l Alcohol l Dexamethasone l Megestrol acetate l Tetrahydrocannabinol (THC) l Androgens l Alcohol l Dexamethasone l Megestrol acetate l Tetrahydrocannabinol (THC) l Androgens

Management of fatigue / weakness... l Promote energy conservation l Evaluate medications l Optimize fluid, electrolyte intake l Permission to rest l Clarify role of underlying illness l Educate, support patient, family l Include other disciplines l Promote energy conservation l Evaluate medications l Optimize fluid, electrolyte intake l Permission to rest l Clarify role of underlying illness l Educate, support patient, family l Include other disciplines

... Management of fatigue / weakness l Dexamethasone feeling of well-being, increased energy effect may wane after 4-6 weeks continue until death l Methylphenidate l Dexamethasone feeling of well-being, increased energy effect may wane after 4-6 weeks continue until death l Methylphenidate

Fluid balance / edema... l Frequently associated with advanced illness l Hypoalbuminemia  decreased oncotic pressure l Venous or lymphatic obstruction may contribute l Frequently associated with advanced illness l Hypoalbuminemia  decreased oncotic pressure l Venous or lymphatic obstruction may contribute

... Fluid balance / edema l Limit or avoid IV fluids l Urine output will be low l Drink some fluids with salt l Fragile skin l Limit or avoid IV fluids l Urine output will be low l Drink some fluids with salt l Fragile skin

Skin l Hygiene l Protection l Support l Hygiene l Protection l Support

Pressure (decubitus) ulcers l Prolonged pressure l Inactivity l Closely associated with mortality l Easier to prevent than treat l Prolonged pressure l Inactivity l Closely associated with mortality l Easier to prevent than treat

Odors l Topical and / or systemic antibiotics metronidazole silver sulfadiazine l Kitty litter l Activated charcoal l Vinegar l Burning candles l Topical and / or systemic antibiotics metronidazole silver sulfadiazine l Kitty litter l Activated charcoal l Vinegar l Burning candles

Insomnia l Assessment of sleep l Other unrelieved symptoms l Use family to help assess l Assessment of sleep l Other unrelieved symptoms l Use family to help assess

Management of insomnia... l Regular sleep schedule, avoid staying in bed l Avoid caffeine, assess alcohol intake l Cognitive / physical stimulation l Avoid overstimulation l Control pain during the night l Relaxation, imagery l Regular sleep schedule, avoid staying in bed l Avoid caffeine, assess alcohol intake l Cognitive / physical stimulation l Avoid overstimulation l Control pain during the night l Relaxation, imagery

... Management of insomnia l Antihistamines l Benzodiazepines l Neuroleptics l Sedating antidepressant (trazodone) l Careful titration l Attention to adverse effects l Antihistamines l Benzodiazepines l Neuroleptics l Sedating antidepressant (trazodone) l Careful titration l Attention to adverse effects

EPECEPECEPECEPEC EPECEPECEPECEPEC Common Physical Symptoms Summary Summary