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

2. 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

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

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

5. Common Symptoms
Respiratory
Dyspnea
Cough
Excessive Secretions

6. GI
Anorexia
Constipation
Diarrhea
Nausea/Vomiting
Obstruction

7. General/Systemic
Fatigue
Weakness
Insomnia

8. Psychological
Depression
Anxiety
Delirium

9. 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

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

11. Causes
Pulmonary
Cardiac
Neuromuscular
Other

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

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

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

15. 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

16. 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

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

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

19. Pharmacologic Interventions for Cough
Suppressants/expectorants
Antibiotics
Steroids
Anticholinergics

20. Non Pharmacologic Interventions for Cough
Chest PT
Humidifier
Positioning

21. 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

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

23. Pharmacologic Interventions
Antibiotics
Bronchodilators
Mucolytic agents-thin secretions
Antihistamines
Steroids

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

25. Causes of Anorexia and Cachexia
Disease related
Psychological
Treatment related

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

27. Treatment Dietary consultation Medications
Parenteral/enteral nutrition
Odor control
Counseling

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

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

30. Assessment Bowel history Abdominal assessment
Rectal assessment if appropriate
Medication review

31. 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

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

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

34. Causes Disease related Malabsorption Concurrent diseases Psychological
Treatment related

35. Assessment
Bowel history
Medication review
Infection process

36. Treatment Treat underlying cause Dietary modifications Hydration
Pharmacologic agents

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

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

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

40. Assessment
Physical exam
History
Lab values

41. Pharmacologic Treatment
Anticholinergics
Antihistamines
Steroids
Prokinetic Agents
Other

42. 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

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

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

45. Vestibular
Meclizine or hydroxyzine 25 mg PO TID

46. Non Drug Treatment
Distraction
Dietary
Small/slow feedings

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

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

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

50. Causes
Disease related
Psychological
Treatment related

51. Assessment
Subjective
Objective
Lab data

52. 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

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

54. Causes
Disease related
Psychological
Treatment related

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

56. 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?)

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

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

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

60. Causes
Medications
Uncertainty

61. Assessment
Physical symptoms
Cognitive symptoms

62. Pharmacologic Interventions
Antidepressants
Benzodiazepines/anticonvulsants
Neuroleptics

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

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

65. Causes
Infection
Medications
Hypoxemia
Bladder distention
Constipation

66. Assessment
Physical exam
History
Spiritual distress
Other symptoms

67. Treatment Pharmacologic Evaluate medications Reorientation
Relaxation/distraction
Hydration

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

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

70. Questions????

71. Shirley Brogley ACHPN, ANP-BC
Supportive and Palliative Care, HFG Cancer Center