1. Palliative Care: Non pain symptoms Elizabeth Whiteman, M.D.

2. Goals and Objectives Be able to review and recognize other non- pain symptoms in palliative care Be able to assess and control non-pain symptoms Assist in treatment coordinating with other needed treatments Understand use of non pharmacologic interventions Understand how to use pharmacologic treatments and prevent new side effects

3. Non Pain Symptoms  Multiple “other” symptoms that can cause significant problems at end of life  Importance of these symptoms has been found in studies to be a significant burden on patients  Management and control of symptoms is the responsibility of the all the physicians and nurses caring for their patients  Symptoms can and should be addressed during active treatment as well as with end of life

4. Non Pain Symptoms Dyspnea Constipation Nausea and Vomiting Anorexia, weight loss and cachexia Fatigue and weakness Depression, Anxiety and insomnia Delirium and agitation Last Hours (days)

5. Case 1 80 year old patient with metastatic lung cancer and COPD. He is living at home and complains of severe shortness of breath with minimal exertion. He still smokes 3 cigarettes a day and has a chronic cough. He is aware of his prognosis and is DNR. His O2 sat is 92% on room air on O2 4L nasal cannula 24 hours a day What can we recommend to help his shortness of breath?

6. A. Set a smoking quit date and refer to a stop smoking group B. Remind him of the importance of a strict low salt diet C. Morphine Sulfate 2.5-5mg every 4 hours as needed for shortness of breath D. Add diuretic for fluid overload E. Increase his oxygen to 5L

7. Answer C Opioids are safe and effective for the relief of dyspnea They do not cause decrease in oxygen saturation When used appropriately patients report less breathlessness and improved exercise tolerance Monitor for symptom control per patients report, titrate up as per symptoms

8. Dyspnea Assess cause of symptom “short of breath” ▫Cancer related ▫Cardiac or CHF ▫Infection ▫COPD or underlying lung disease ▫Anxiety ▫Spiritual suffering

9. Dyspnea Treatment ▫Non pharmacologic  Elevate head of bed  Breathing exercises  Relaxation techniques  Rest between exertion (energy conserve)  Electric fan for increased air flow  Room with ventilation and windows  Oxygen 2-4 L nasal cannula as needed

10. Dyspnea Pharmacologic ▫Narcotics: Morphine, Oxycodone, Hydromorphone ▫Benzodiazepines to relieve breathlessness ▫Diuretics if fluid overload ▫Steroids for asthma or inflammation ▫Inhalers or nebulizer for bronchospasm ▫Drying agents if increased secretions  Scopalamine patch, Glycopyrrolate, atropine drops sublingual STOP the cause: excess IV fluids, G tube feeds

11. Case 2  A 75 year old woman with metastatic breast cancer is admitted with new abdominal pain and no bowel movement for 10 days. She also has no appetite and feels nausea. She is on long acting Morphine 30mg bid which controls her pain from the cancer. Her abdomen is distended and there is firm hard stool in her rectum. She has bowel sounds and the x-ray shows stool throughout the colon.  What is the first thing you can do to help her abdominal pain?

12. A. Stop her Morphine B. Keep her NPO and place an NG tube C. Start Metoclopramide IV around the clock D. Give her an enema and start an oral laxative E. Call surgery to evaluate for possible obstruction

13. Answer D Constipation likely due to opioids Patients on opioids need to be on preventative treatment for constipation Full assessment of cause should be investigated Treatment of coexisting symptoms also needs to be managed (BUT TREAT UNDERLYING CAUSE) Avoid causing return of other symptoms and keep pain treatment also in mind

14. Constipation Discomfort associated with reduced frequency of bowel movements Causes can be multifactorial ▫Medications ▫Dehydration ▫Less physical activity ▫Metabolic abnormalities ▫Decreased oral intake ▫Mechanical obstruction

15. Constipation Treatment ▫Non Pharmacologic  Increase oral intake and fluids  Increase mobility and activity if able  Increase fiber and fruit juices, prunes etc  Positional : commode, sitting upright  Privacy

16. Pharmacologic ▫Stool softeners ▫Stimulant laxatives  senna, dulcolax ▫Osmotic laxatives  Milk of magnesia, lactulose, polyethylene glycol ▫Prokinetic agents  Metoclopramide ▫Rectal  Suppositories, enemas, manual disimpaction

17. Nausea and Vomiting  Nausea is the unpleasant subjective sensation as a result from stimulation in the GI tract the chemoreceptor trigger zone in the brain, the vestibular apparatus and the cerebral cortex.  Vomiting is the reflex that comes after stimulation of one or more of these regions  Associated with many advanced diseases  Can also be a result of therapeutic interventions  Thorough assessment of nausea and vomiting is important to understand the cause and treatment options

18. Nausea and Vomiting Non Pharmacologic ▫Treat other symptoms (pain, short of breath, constipation, anxiety) ▫Avoid foods that are not pleasing to patient ▫Relaxation and breathing, swallowing techniques ▫Loose, unrestrictive clothing ▫Avoid lying flat 2 hours after eating ▫Encourage more frequent, small meals

19. Nausea and Vomiting Pharmacologic ▫Gastrointestinal stimulation  Diphenhydramine, antispasmodics, prokinetic agents ▫Vestibular  Metoclopramide, scopalamine, meclizine ▫Cerebral cortex (increased pressure)  Steroids, neuroleptics ▫Chemoreceptor trigger zone (drug toxins, disease)  Evaluate causative agents (chemo, opioids)  Dopamine agonists, serotonin antagonists, anticholinergic drugs.

20. Case 3 A 60 year old man with leukemia comes in with new confusion and agitation. He is currently undergoing chemotherapy and during his treatment he started pulling out his iv lines and became agitated. He usually lives at home with his wife and daughter and they say he has become more confused the last 2-3 weeks. They are concerned he has dementia. He was recently started on Diazepam for sleep.

21. What is the correct treatment to first control his symptoms ▫A. STAT brain CT to rule out brain tumor ▫B. Antipsychotic to control agitation ▫C. Increase Diazepam to BID ▫D. Tell the family he likely has dementia and there is no cure.

22. Answer B Antipsychotics for acute agitation to help calm patient and complete work up. Need to rule out other causes of new decline such as metastasis, metabolic Assess if medications need adjustment or if medication is causing problems Delirium is an acute and fluctuation change in mental status and alertness. Causes can be multifactorial. Usually not permanent.

23. Delirium Occurs in up to 83% of patients near end of life Reduced level of consciousness or memory loss Disturbance of sleep wake cycle Delusions, hallucinations or paranoia Symptoms develop over a short period, tend to wax and wane Symptoms can become worse if not treated

24. Delirium Medical assessment ▫Examine new medical problems: infections, dehydration, depression, anxiety, progression of disease, metabolic abnormalities Non Pharmacologic Treatments ▫Orientation ▫Increase sleep cycle at night ▫Ambulate and activity during the day ▫Vision and hearing aides ▫Increased socialization

25. Pharmacologic Treatment ▫Decrease or stop medication that can cause problems  Sedation medications, anticholinergics, sleep aides ▫Antipsychotic medications  Haloperidol or atypical antipsychotics ▫Antidepressants or anxiolytics if indicated ▫Short acting sleep agents or antipsychotics for sleep prn until improved

26. Non Pain Symptom Management Many other symptoms that can cause distress in severe illness or at end of life Assess by listening to patients report of symptoms and monitoring Communication between the patient and family with the medical care team Use team approach; including social workers, chaplain, caregivers to give entire patient care.

27. Resources Berger, A.; Portenoy, R.; and Weissman, D. Principles and Practice of Supportive Oncology. Lippincott-Raven. 1998. Doyle, D.; Hanks, G.W.C.; and MacDonald, N. Oxford Textbook of Palliative Medicine. Oxford University Press. 2001. Betty R. Ferrell and Nessa Coyle, Textbook of Palliative Nursing, second edition 2010. O'Brien, T, Welsh J, Dunn FG. ABC of palliative care: Non-malignant conditions. BMJ 1998; 316: 286-289. Storey, P, UNIPAC, Third Edition, BOOK 4: Management of Selected Non-Pain Symptoms in the Terminally Ill, 2004.