1. Managing Symptoms in Palliative Care

2. Aims  To gain an awareness of the most common symptoms in patients with life limiting diseases and why these occur  To identify your role in supporting patients and their families with these symptoms  To understand how to promote patient comfort and improve the quality of care

3. What are common symptoms?  Breathlessness  Fatigue

4. Breathlessness

5.  What are the causes of breathlessness

6. Causes  Primary and secondary cancer  Heart failure  COPD  Anxiety and fear  Fluid overload  Respiratory muscle weakness  Infection  Anaemia  Others?

7. How it feels…  Difficult, laboured and uncomfortable breathing  May experience significant panic associated with breathlessness  Impacts on quality of life

8. Dyspnoea  Causes anxiety in patients and carers  Patients describe -Unpleasant sensation of not being able to breathe easily -Unpleasant sensation of not being able to breathe easily -Feelings of exhaustion -Feelings of exhaustion -Tightness of chest -Tightness of chest -Extreme fear of suffocation or drowning -Extreme fear of suffocation or drowning  Panic and anxiety – leads to an increase in rate of breathing

10. Impacts upon:  Social – work, family role, house bound  Spiritual – meaning in and of life  Psychological – fear, anxiety, depression  Physical – oxygen dependency, loss of function and independence

11. Breathing Retraining Strategies already used by patients -slowing down -slowing down -avoiding triggers -avoiding triggers -pacing -pacing -deep breathing -deep breathing -relaxing -relaxing -use of fans -use of fans

12. Breathing Retraining Breathing Exercises  Sitting in a comfortable position gently squeeze your shoulders up to your ears, then let go: repeat a couple of times  Start by relaxing your jaw and gently sigh out through your mouth. In your own time breathe in through your nose, if possible, and then gently sigh out again.

13. Breathing Retraining  Place your hands across your lower ribs, just above your waist. Breathe out through your mouth, letting your ribs sink in as far as possible. Then, breathing in through your nose or mouth, feel your ribs expand outwards against your hands. Gently breathe out to start again.  Repeat three or four times

14. Square Breathing  Focus on a rectangle, visualise the right hand corner, then following the line down, sigh out until you get to the bottom right hand corner. Take a breath in, until you get to the bottom left hand corner, then sigh out until you get to the top left hand corner and breathe in until you reach the right hand corner.  Repeat this two or three times.

15. What is your role?  Communication – listening  Recognition that breathlessness is frightening and uncomfortable  Maintain dignity by providing help the patient wants – promote independence  Help adjustment to limitations  Promote calm environment  Cold air/Fans can be very effective  Report symptoms and assess effect of intervention

16. FATIGUE

17. Fatigue in Palliative Care  Subjective, unpleasant symptom which ranges from tiredness to complete exhaustion  Interferes with individuals ability to function normally  Common in cancer, chronic, life limiting diseases

18. Fatigue  In healthy people fatigue is relieved by sleep and rest  In cancer and chronic diseases patients wake up feeling tired no matter how long they have slept  Many causes  Disease itself, treatment, psychological, social

19. Why is Fatigue Difficult to Manage  Often has more than one cause  Patients find it difficult to explain/report  Often lack of knowledge by health care professionals  Belief that nothing can be done  Failure to appreciate effect on the patient/family  Knowing how to assess it

20. What Can Be Done  Deal with the cause if possible  Pain management, infection, treat blood abnormalities  Can anything be done?  Alter or change treatment  Reassure patient that if caused by cancer treatment it can improve.

21. Your Role In Fatigue  Crucial – Important to believe the patient  Often provide basic care and you can recognise changes or inability to self care/mobilise  Identify signs that may be cause fatigue e.g. breathlessness, panicky, not keen to do anything, withdrawn  Know the patients limitations  Encourage and support  Encourage gentle exercise and mobility  Referrals to other HCP e.g. prior to discharge.