To prevent and relieve suffering, and promote quality of life at every stage of life

Common Symptoms Frank D. Ferris, MD Medical Director, Palliative Care Standards C ENTER F OR P ALLIATIVE S TUDIES San Diego Hospice and Palliative Care “Education and Research in the Art and Science of Palliative Care” Department of Family and Preventative Medicine, UCSD School of Medicine Department of Family and Community Medicine, and Joint Center for Bioethics, University of Toronto Frank D. Ferris, MD Medical Director, Palliative Care Standards C ENTER F OR P ALLIATIVE S TUDIES San Diego Hospice and Palliative Care “Education and Research in the Art and Science of Palliative Care” Department of Family and Preventative Medicine, UCSD School of Medicine Department of Family and Community Medicine, and Joint Center for Bioethics, University of Toronto

Objectives Know general guidelines for managing non-pain symptoms Know how to assess and manage common symptoms Publications / presentations Know general guidelines for managing non-pain symptoms Know how to assess and manage common symptoms Publications / presentations

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

... General guidelines Provide education, support Involve entire interdisciplinary team Reassess frequently Provide education, support Involve entire interdisciplinary team Reassess frequently

HIV Wasting

Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days  inadequate nutrient intake  excessive nutrient loss  metabolic dysregulation Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days  inadequate nutrient intake  excessive nutrient loss  metabolic dysregulation

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

... Management of anorexia / cachexia Alcohol Megestrol acetate Dexamethasone Dronabinol Androgens, eg, testosterone Alcohol Megestrol acetate Dexamethasone Dronabinol Androgens, eg, testosterone

Fatigue / Weakness

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

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

Fever / Sweats

Management of fever / sweats Paracetamol (acetaminophen) NSAIDs, eg, ibuprofen Corticosteroids, eg, dexamethasone Anticholinergics, eg, scopolamine Rehydration Bathing, drying Paracetamol (acetaminophen) NSAIDs, eg, ibuprofen Corticosteroids, eg, dexamethasone Anticholinergics, eg, scopolamine Rehydration Bathing, drying

Nausea / Vomiting

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

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

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

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

Acetylcholine antagonists (anticholinergics) Scopolamine Atropine Scopolamine Atropine

Dopamine antagonists Haloperidol Prochlorperazine Metoclopramide (also prokinetic) Haloperidol Prochlorperazine Metoclopramide (also prokinetic)

Histamine antagonists (antihistamines) Diphenhydramine Meclizine Hydroxyzine Diphenhydramine Meclizine Hydroxyzine

Serotonin antagonists Ondansetron Granisetron Ondansetron Granisetron

Antacids H 2 receptor antagonists  cimetidine  ranitidine Proton pump inhibitors  omeprazole Antacids H 2 receptor antagonists  cimetidine  ranitidine Proton pump inhibitors  omeprazole

Cytoprotective agents Misoprostol Proton pump inhibitors  omeprazole Misoprostol Proton pump inhibitors  omeprazole

Other medications Dexamethasone Tetrahydrocannabinol Lorazepam Octreotide Dexamethasone Tetrahydrocannabinol Lorazepam Octreotide

Constipation

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

Management of constipation General measures  establish “normal” bowel pattern  regular toileting  gastrocolic reflex General measures  establish “normal” bowel pattern  regular toileting  gastrocolic reflex Specific measures  stimulants  osmotics  detergents  lubricants  large volume enemas

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

Osmotic laxatives Milk of magnesia (other Mg salts) Lactulose Polyethylene glycol Sorbitol Magnesium citrate Milk of magnesia (other Mg salts) Lactulose Polyethylene glycol Sorbitol Magnesium citrate

Surfactant laxatives (stool softeners) Sodium docusate Calcium docusate Phosphosoda enema prn Sodium docusate Calcium docusate Phosphosoda enema prn

Prokinetic agents Metoclopramide

Lubricant stimulants Glycerin suppositories Oils  mineral  peanut Glycerin suppositories Oils  mineral  peanut

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

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

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

Diarrhea

Causes of diarrhea Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress

Management of diarrhea Establish “normal” bowel pattern Treat underlying cause Avoid gas-forming foods Increase bulk, i.e., fiber Transient, mild diarrhea  bismuth salts Establish “normal” bowel pattern Treat underlying cause Avoid gas-forming foods Increase bulk, i.e., fiber Transient, mild diarrhea  bismuth salts

Management of persistent diarrhea Rehydration  Oral salt containing fluids  Parenteral Loperamide Diphenoxylate / atropine Tincture of opium Octreotide Rehydration  Oral salt containing fluids  Parenteral Loperamide Diphenoxylate / atropine Tincture of opium Octreotide

Shortness of Breath (Dyspnea)

Breathlessness (dyspnea)... Described as  shortness of breath  a smothering feeling  inability to get enough air  suffocation Described as  shortness of breath  a smothering feeling  inability to get enough air  suffocation

... Breathlessness (dyspnea) Only reliable measure is patient self- report Respiratory rate, pO 2, blood gas determinations DO NOT correlate with the feeling of breathlessness Prevalence 12 – 74% Only reliable measure is patient self- report Respiratory rate, pO 2, blood gas determinations DO NOT correlate with the feeling of breathlessness Prevalence 12 – 74%

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

Management of breathlessness... Treat the underlying cause  antibiotics  avoid fluid overload  dry secretions Mechanical ventilation Treat the underlying cause  antibiotics  avoid fluid overload  dry secretions Mechanical ventilation

... Management of breathlessness Symptomatic management  oxygen  opioids  anxiolytics  nonpharmacologic interventions Symptomatic management  oxygen  opioids  anxiolytics  nonpharmacologic interventions

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

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

Anxiolytics Safe in combination with opioids  lorazepam mg po q 1 h prn until settled then dose routinely q 4–6 h to keep settled 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... Reassure, work to manage anxiety Behavioral approaches, eg, relaxation, distraction, hypnosis Limit the number of people in the room Open window Reassure, work to manage anxiety Behavioral approaches, eg, relaxation, distraction, hypnosis Limit the number of people in the room Open window

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

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

Common Symptoms Summary Common Symptoms Summary