END-OF-LIFE CARE: Module 5

END-OF-LIFE CARE: Module 5
ELC Module 5: Non-pain Symptom Management END-OF-LIFE CARE: Module 5 Non-Pain Symptom Management [Teacher’s Note: this review of teaching applies if you presented the previous module.] Let’s take a few moments to review the goals you set for yourself in the last seminar. Did you have an opportunity to implement any of your goals? If so, what happened? [Teacher’s Note: If no goals were worked on, ask participants to discuss either of the following:] What questions or insights have you had about the material covered in the last seminar? Would you like to discuss any ideas from the readings? [Teacher’s Note: For Module 5, you will need the following from the handbook:] 5.1 Outline 5.2 Causes of Nausea and Vomiting 5.3 Symptom Analysis Checklist 5.4 Bibliography (Provide 3X5 Cards for Goals) Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

ELC Module 5: Non-pain Symptom Management
Case Imagine you have advanced pancreatic cancer. You’ve lost 30 pounds over the past few months. There is no evidence of GI obstruction and you are not nauseated. You are very weak, and are now bedridden, with no appetite. Your mouth is dry. Your spouse keeps trying to get you to eat and you try, but you just can’t do it. You keep wondering why this is happening, and your spouse is very upset. You are admitted to the hospital and lab tests reveal that you are dehydrated. The intern comes to insert an IV. [Teacher’s Note: Ask a learner to read this case to the group.] In this module we focus on the science and the art of managing symptoms at the end of life. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Learning Objectives Increase understanding of how physical and mental factors affect symptomatology Be able to use this understanding in the treatment of patients suffering from nausea and vomiting, dyspnea, and cachexia/anorexia/asthenia Incorporate this content into your clinical teaching By the end of this session you will be able to… Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Outline of Module Non-pain symptoms at EOL Symptom analysis checklist Nausea and vomiting Break Dyspnea ‘Terminal Syndrome Characterized by Retained Secretions’ Cachexia/anorexia/asthenia Handout: Outline We will use case studies, brainstorm, and discussion in this seminar. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Symptoms as Clues A physical or mental phenomenon, circumstance or change of condition arising from and accompanying a disorder and constituting evidence for it… specifically a subjective indicator perceptible to the patient and as opposed to an objective one (compare with sign). The New Shorter Oxford English Dictionary What does the word ‘symptom’ mean to you? Here is one definition. [Teacher’s Note: Ask a learner to read this aloud.] Symptoms traditionally have been considered primarily important in medicine as clues to a mystery of underlying disease. Once you’ve solved the mystery the symptoms are no longer so important. Example: A patient with liver cancer presents with nausea. Typical treatment would be to prescribe promethazine or prochlorperazine. But knowing what we know about the disease may give us clues to the physiology of the symptom. What might be causing this patient’s nausea? [Teacher’s Note: Most learners will say they do not know.] For example, liver cancer can compress the stomach, or the patient may have dysmotility due to ascites or drugs used. While symptoms can tell us about disease, diseases can also provide useful clues. Knowing about the disease can help us understand the pathophysiology of the symptom and how to treat it. It is a two-way street. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Disease as a Clue to the Symptom
ELC Module 5: Non-pain Symptom Management Disease as a Clue to the Symptom Questions to ask: How does the disease give rise to the symptom? What cognitive, affective, and spiritual components are involved? The patient’s experience of the symptom is also key to treatment. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

From the Patient’s Perspective
ELC Module 5: Non-pain Symptom Management From the Patient’s Perspective A symptom is what is bothersome A symptom is a troubling experience. Symptoms do not exist in a vacuum. Each patient’s experience is also shaped by additional forces such as culture, values, and relationships. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Symptom Analysis Checklist
ELC Module 5: Non-pain Symptom Management Symptom Analysis Checklist Physiological Factors Local Central Mental Factors Cognitive Affective Spiritual Any one of these factors can magnify or minimize the experience. Understanding (positive and negative) aspects of the patient’s experience helps lead to a strategy. We want to address those aspects that magnify the bothersome experience for a given patient, and support those aspects that tend to minimize his or her suffering. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Skills Practice: Patient with pain symptoms due to metastatic bone cancer Physiological factors Local: Central: Mental Factors Cognitive: Affective: Spiritual: Since it is artificial to divide symptoms between pain and non pain, and you know quite a lot about pain, let’s practice filling this in first for a patient with pain symptoms. What local factors might contribute to this patient’s pain? [e.g., osteoclast activity] What local factors might minimize it? [e.g., weight shifting (avoiding pressure)] What physical central factors might magnify the patient’s perception of pain? [e.g., hormones in flight or flight syndrome] What central factors might mitigate it? [e.g., endogenous opioids] What cognitive factors might magnify the pain? [e.g., assumption that pain means cancer is worsening or death is near] What cognitive factors might minimize the pain? [e.g., distraction, humor, reframing the pain as a challenge] What affective factors might magnify the pain? [e.g., fear, perception of pain, panic, anger, anxiety, worries, frustration with disability] What affective factors might minimize the pain? [e.g., positive emotions; love, gratitude, joy in being cared for] What spiritual factors might magnify the pain? [e.g., interpreting it as God’s punishment for sins] What spiritual factors might minimize the pain? [e.g., faith; a sense of connection to the suffering of all living creatures; a sense of being tested] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Non-Pain Symptoms at the EOL
ELC Module 5: Non-pain Symptom Management Non-Pain Symptoms at the EOL Akathesia Anhedonia Anorexia Anxiety Colic Confusion Constipation Cough Crying Death rattle/secretions Diarrhea Dizziness Drooling Dry skin Dysarthria Dysgeusia Dyspepsia Dysphagia Dysphoria Dyspnea Dysuria Failure to thrive Fatigue Fear Fecal incontinence Fever Flatulence Halitosis Hallucinations Hearing loss Hiccups Impotence Irritability Memory loss Mucositis Muscle spasms Nausea Odor Panic attacks Peripheral edema Photosensitivity Polydipsia Polyuria Pruritus Restlessness Sexual dysfunction Sleep disorders Stomatitis Taste alterations Urinary frequency Urinary incontinence Visual problems Vomiting Xerostomia Index, Oxford Textbook of Palliative Medicine, 1998 Here are some of the non-pain symptoms that can arise at the end of life (54 symptoms listed in the Oxford Textbook of Palliative Medicine, 1998) As you see, there are too many symptoms to address each one directly here. We will apply the symptom analysis checklist to some of the more common ones, starting with nausea and vomiting. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Nausea & Vomiting When you were a resident (or if you are a resident now: when you were in medical school), what were you taught about antiemetics? If you didn’t learn much about nausea and vomiting, you are not alone. This is not unusual in the educational system. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Nausea & Vomiting As Protective Mechanisms
ELC Module 5: Non-pain Symptom Management Nausea & Vomiting As Protective Mechanisms Serial barriers: 1. Sight, smell, taste 2. Chemoreceptors and mechanoreceptors 3. Brain receptors 4. Message to vomit residual gut contents Nausea and vomiting probably arose as protective mechanisms against the ingestion of toxic substances. Consider how this might work adaptively if you were eating an unknown plant. First the senses – sight, smell and taste (and remember). If these fail, then chemoreceptors and mechanoreceptors (stretch receptors) are invoked in attempt to avoid absorption. If these fail, brain receptors try to detect toxins in the blood. When detected, a message is sent to vomit residual gut contents. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

A Central Final Pathway for Nausea
ELC Module 5: Non-pain Symptom Management A Central Final Pathway for Nausea (Dopamine, Serotonin) (???) CNS CTZ VOMIT CENTER (Acetylcholine, Histamine) [Teacher’s Note: This is the key overhead for the nausea section.] These zones have specific receptors responsible for generating nausea signals. Blocking these receptors is a logical mechanism for blocking nausea arising from a particular zone. The vomit center has intrinsic acetylcholine and histamine receptors. This may be why drugs blocking these receptors have some effect in most forms of nausea. Vestibular Apparatus GI Tract (Acetylcholine, Histamine) (Acetylcholine, Histamine, Serotonin + mechanoreceptors) Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Receptor Affinity Common Antiemetics
ELC Module 5: Non-pain Symptom Management Receptor Affinity Common Antiemetics Drug Receptors Dopamine Musc. Chol. Histamine Scopalomine >10, >10,000 Promethazine Prochlorperazine Chlorpromazine Metoclopramide >10,000 1,000 Haloperidol >10,000 1,600 Potency: K1 (nanomolar) The lower the number, the stronger this agent is at blocking this receptor Adapted from Peroutka and Snyder, 1982 We know from lab models that different agents bind specific receptors very differently. Note the inverse relationship: The lower the number the more potent that drug is at that site. Understanding relative potency at different receptors allows for a rational approach. [Teacher’s Note: This is an area in which more work needs to be done. No randomized controlled trials of promethazine and prochlorperazine have been conducted as of yet.] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Causes of Nausea & Vomiting
ELC Module 5: Non-pain Symptom Management Causes of Nausea & Vomiting Vestibular Obstruction Mind Dysmotility Infection (irritation) Toxins (taste and other senses) Handout: Causes of Nausea and Vomiting Here is an easy way to remember causes of nausea and vomiting. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Vestibular Apparatus Nausea with head movement Medicated by acetylcholine and histamine receptors Most anticholinergic, antihistamine drugs will help Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Obstruction/Opioids Constipation = most common cause External or internal obstruction Mediated by mechanoreceptors and/or chemoreceptors Controversy as to best medication for true bowel obstruction Anti-constipation meds for constipation Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Mind Memory, meaning, and emotions can be very powerful Manipulate taste and other senses Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Dysmotility Multiple causes Upper intestinal dysmotility is very common Prokinetics: Metoclopramide (upper only) Senna (lower only) Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Infection/Irritation
ELC Module 5: Non-pain Symptom Management Infection/Irritation Mediated through chemoreceptors Gut and adjacent organ inflammation can trigger Anticholinergic/antihistaminic medications can help Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Toxins Most important source: medications Various mechanisms of inducing nausea Treatment depends on mechanism of action Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Opioid-Related Nausea
ELC Module 5: Non-pain Symptom Management Opioid-Related Nausea Incidence of dysmotility caused by opioids may be underestimated Haloperidol recommended for nausea related to chemoreceptor trigger zone (CTZ) Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

5HT3 Antagonists May have a variety of uses Minimally tested outside of their use in chemotherapy-related nausea Expensive In addition, neurokinin antagonists are new on the horizon. Bottom line: Nausea is quite treatable and should not be accepted as a normal side effect of dying. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Symptom Analysis Checklist
ELC Module 5: Non-pain Symptom Management Symptom Analysis Checklist Physiological Factors Local Central Mental Cognitive Affective Spiritual Handout: Symptom Analysis Checklist We’re going to spend a little time now on dyspnea. A lot of very good therapy exists for dyspnea in heart failure, asthma, pneumonia, etc. that you are well trained in. We are not going to focus on that. This is not a comprehensive look at how to treat dyspnea, but it will address aspects of dyspnea at the end of life that may be unfamiliar to some of you. Let’s consider dyspnea in three situations that are dramatically different. [Teacher’s Note: If you are teaching the full seminar, this would be a good place for a brief break. For the next exercise, you may want to pick a learner to run during the break around the building or up and down stairs for 5 minutes.] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Exercise 1: The Runner Are you dyspneic? Short of breath? What is your O2 saturation level? What is happening locally in you chest? What do you think about your run? Any spiritual importance? Are you suffering? [Teacher’s Note: If you have asked someone to run during the break, quickly take his or her O2 level if using Sat meter. Alternately, you may ask a learner to imagine having just run around the building or up and down stairs for 5 minutes.] Let’s use the symptom analysis model to assess what’s going on. [Teacher’s Note: Ask, or have others ask him or her these questions.] Key point: One can be dyspneic with normal 02 levels. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Exercise 2: Being Held Under Water
ELC Module 5: Non-pain Symptom Management Exercise 2: Being Held Under Water Are you dyspneic? Short of breath? What is your O2 saturation level? What is happening locally in you chest? What do you think about your run? Any spiritual importance? Are you suffering? [Teacher’s Note: Ask participants to hold their breath for about a minute. Then measure someone’s O2 level if using Sat meter.] Now imagine you are being held under water against your will. Hold your breath as long as you can. Raise your hand with the first hint of needing to breathe. Meanwhile, let’s go through the same set of questions: [Interview the group.] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Exercise 3: Lung Cancer Imagine that you have lung cancer, on top of pre-existing COPD You are getting winded with the least possible exercise. Coming back from the bathroom to the bed you are now very dyspneic You wish there was a window you could open The nurse measures your O2 Sat There is a low-pitched beeping sound, which you know is not good The nurse looks distressed and rushes from the room [Teacher’s Note: You may use this exercise as a brief opportunity for you to model sharing bad news, along with making the teaching points about dyspnea.] Why do you want the window open? (The fresh breeze makes me feel better) What is your affective state? (Frustrated, may feel depressed, or anxious like the nurse) What are you thinking (My Sat must be low, so I’m worse. Is this a sign that I’m dying? Pretty soon I won’t be able to get out of bed. It’s my own damn fault for smoking) What is your spiritual state (Questioning why this is happening to me, God, wondering what it will be like to be dead) Are you suffering? (Yes!) Clinical pearl: In patients who cannot tolerate or do not want oxygen, a small fan may relieve dyspnea. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Treating Dyspnea Physiological Factors Local: Fan, cool breeze Central: WOB may be particularly responsive to low dose opioids Mental factors Cognitive: Education, reframing Affective: Emotional support, benzodiazepines for panic sensation Let’s pull this together into a framework for treatment of dyspnea in the dying. Traditional treatment focuses only on the lungs, the physical. It is a big barrier to stop with that. There is a phenomenal 2-way link between the mind and the lungs. Assessing the physiological and mental status of the patient enables you to treat appropriately. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Dyspnea in the Dying Common - 70% of patients in last 6 weeks of life Reuben & Mor, 1986 Care has traditionally focused more on lung physiology than central processes Not always correlated with oxygen level Analysis of all the components of dyspnea leads to effective treatment. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

‘Terminal Syndrome Characterized by Retained Secretions’
ELC Module 5: Non-pain Symptom Management ‘Terminal Syndrome Characterized by Retained Secretions’ Relative lack of cough Not always associated with dyspnea Deep suctioning ineffective Hydration may flood lungs Because patient is unable to cough Use of antibiotics, IV fluids controversial In Module 1 we touched briefly on something that is sometimes referred to as ‘terminal syndrome characterized by retained secretions.’ Now let’s talk more about how to treat it. There is no good term for this syndrome, so we’re using this unwieldy phrase until something better comes along. There may or may not be any bacterial evidence of pneumonia with this syndrome. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Treatment of this Terminal Syndrome
ELC Module 5: Non-pain Symptom Management Treatment of this Terminal Syndrome Peaceful environment For dyspnea Opioid-naïve: 2-4 mg SC morphine or equivalent q1-2 hours On opioid: increase dose by 25% Lorazepam or chlorpromazine for agitation For secretions Oxygen, fan Support the patient and coach the family. You may need to educate the nurses as well. If the patient is taking an opioid, increase the dose by 25%. There isn’t much evidence to support this in the literature, but from clinical experience, work of breathing (WOB) appears to be affected. What might we give for secretions? Anticholinergic agents Scopolamine, atropine eye drops Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Case Exercise Imagine you have advanced pancreatic cancer. You’ve lost 30 pounds over the past few months. There is no evidence of GI obstruction and you are not nauseated. You are very weak, and are now bedridden, with no appetite. Your mouth is dry. Your spouse keeps trying to get you to eat and you try, but you just can’t do it. You keep wondering why this is happening, and your spouse is very upset. You are admitted to the hospital and lab tests reveal that you are dehydrated. The intern comes to insert an IV. [Teacher’s Note: Ask one of the participants to read this case aloud.] Now the question is: If this is you, do you want the IV? This case raises issues about the advantages and disadvantages of IV, and the preferences of the patient. Two teaching points: 1. We may do things to patients that we might not want ourselves. 2. Most people are unaware of the advantages and disadvantages of IV. [Teacher’s Note: Learners usually want more information, e.g., goals for admission and care. If so, you could tell them, “Good question: Do you think the intern knows what the IV is supposed to accomplish?” Often the answer is that we want access “just in case something happens.”] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Definitions Cachexia = physical wasting Anorexia = lack of appetite Asthenia = weakness, fatigue Problems of weight loss, loss of appetite/thirst, and weakness or fatigue are common to many terminal illnesses. This can be very distressing and, even more than nausea and dyspnea, these symptoms often result in therapies that are controversial. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Physiological Mechanisms
ELC Module 5: Non-pain Symptom Management Physiological Mechanisms Complex physiology Best studied in cancer Key finding: Not the same as starvation Significant physiological differences Often not reversed by artificial feeding There are significant physiological differences between this syndrome and starvation. At least in advanced cancer, refeeding either enterally or via TPN does not lead to weight gain – with rare exceptions. Note: It is important not to over-extrapolate from cancer to some other populations, such as AIDS, where functional status can improve with artificial feeding. Physiological mechanisms may differ among different disease processes. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Cachexia/Anorexia/Asthenia
ELC Module 5: Non-pain Symptom Management Cachexia/Anorexia/Asthenia Strongly correlated with decreased functional status Associated with multiple losses - Appetite and pleasure in eating - Energy level - Independence - Activities of daily living Decreased functional status Key point: These losses can cause serious grief reactions. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Medical Interventions
ELC Module 5: Non-pain Symptom Management Medical Interventions Treat underlying nausea, pain, depression Artificial feeding may or may not be appropriate To increase appetite Megestrol acetate Steroids Cannabinoids Transfusion for anemia May or may not improve asthenia Transfusion for anemia may or may not improve asthenia. The best test is if a prior transfusion helped significantly to improve strength, continued transfusions may be warranted. If the last transfusion did NOT improve strength, it is unlikely that future transfusions will improve appetite. The family or patient may grieve the loss of contact with the physician that comes with the decision not to transfuse any more. Ssupport the need in other ways. Megestrol acetate requires high dose: mg/day. Steroids may themselves cause asthenia through a steroid myopathy. Their effects on strength and lean body mass are less clear; can increase body weight but not lean body mass, so may not improve functioning. Cannabinoids can help with appetite in certain populations, however many geriatric patients find the psychological effects unpleasant. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Psychological Interventions
ELC Module 5: Non-pain Symptom Management Psychological Interventions Treat underlying depression Address loss in patient and family Reflect back losses of nurturing, functional status and independence Help patient/family redefine these losses Coach in new ways to nurture Consider therapies to compensate for functional loss These are not trivial. Physical therapy or occupational therapy may help compensate for functional loss. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Artificial Hydration at the End of Life is Controversial
ELC Module 5: Non-pain Symptom Management Artificial Hydration at the End of Life is Controversial The medical findings are mixed as to whether IV fluids improve quality of life. (Bruera, 2000) Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Brainstorm What are some arguments on both sides of the EOL artificial hydration controversy? What are some arguments on both sides of the end-of-life artificial hydration controversy? [Teacher’s Note: Quickly generate a list, writing down verbatim responses.] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Some Arguments... In Favor: Minimum standard of care ? Greater comfort ? Less confusion, restlessness Against: Not clear that it prolongs life Increases urine output, GI secretions/nausea, & pulmonary secretions with pneumonia Not clear that it alleviates thirst Decreasing fluids acts as natural anesthesia Other people have noted these. There may be less neuromuscular irritability. Some forms of terminal delirium clear with small amounts of hydration. It may allow clearance of toxins, such as opioid metabolites. Although there have been no RCTs on this, it seems to increase pulmonary secretions – there is some controversy here. Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Medical Issues Aside… Some prefer a more ‘natural death’ without artificial hydration Others may see hydration as minimal, humane (if technical) support Important to take patient goals and situation into account Preference for hydration relates to personal and cultural beliefs and values What sort of situations might affect the decision? [Possible answers might include:] Susceptible to wet pneumonia Patient views no IV as abandonment The line is hard to put in While ‘dying with an IV’ has become standard care in most hospitals, the use of hydration at the end-of-life is controversial. One study found that 59% of 27 medical interns with an average of 6 months experience had never cared for a dying patient without an IV. (Hallenbeck & Bergen, 1999) Before we finish, would anyone here like to change their vote regarding whether they want IV hydration when actively dying? Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

Learning Objectives Increase understanding of how physical and mental factors affect symptomatology Be able to use this understanding in the treatment of patients suffering from nausea and vomiting, dyspnea, and cachexia/anorexia/asthenia Incorporate this content into your clinical teaching [Hand out Goal Cards.] We’ve come to the end of the seminar. Our goal with this seminar was to raise awareness and give you some tools to help in the making of difficult decisions. Personal Goal Setting Take a moment to review the learning objectives of this seminar and do a quick self-assessment of what you’ve learned. Please record one goal relevant to today’s seminar content, for each of the following: Your clinical practice Your teaching Your institution Let’s go around the room, and have each of you share your goals. [Teacher’s Note: Each participant presents at least one of his/her goals to the group (more depending upon time). If some goals are not sufficiently behavioral, ask how the goal would be implemented.] Module #5 Copyright © 2003 by Stanford Faculty Development Center End-of-Life Care Curriculum for Medical Teachers Stanford University School of Medicine

END-OF-LIFE CARE: Module 5

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